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This is what a hospital is, among other things — life and science and politics and death, though not necessarily in that soothing order.

Where else but a hospital would highly educated human beings sit in a room respectfully arguing about who does and who does not have the right to be protected against an influenza epidemic that could kill 30 million people, even as that flu is gearing up to sweep across China and into the lives of the people in the room? Where else on earth but in a hospital, with its fearless logic and tightly bound emotional range, would it be possible for a doctor to say in all seriousness that he should be protected against the flu, whereas his daughter — to say nothing of yours, buster — should not be?

That's how people who run hospitals think. Then there's the rest of us — which brings us to the 18th-floor auditorium of Mount Sinai Hospital in downtown Toronto, and why almost everyone in the room wants to know only one thing: What about the bird flu?

Not that the meeting was supposed to go that way. Joe Mapa, the creamy-smooth president and CEO of Mount Sinai, throws this luncheon twice a year to make his board of governors feel they belong to the hospital, and vice-versa. Mount Sinai has done well by its donors, after all — one of the top teaching hospitals in North America, one of the most respected research institutions in the world, the embodiment of the strengths (and some of the weaknesses) of the Canadian health-care system, already displaying the outline of what hospital medicine will look like in 10 years.

To accomplish his mission, Mr. Mapa has called in an array of his most stellar researchers and clinicians to show off the cutting-edge research and clinical work the donors have financed. Joe Mapa calls it feeding "the passion."

There's so much money in the audience you could practically lie down in the stuff. People with entire wings and whole buildings named after them: Joe Lebovic, the suburban home king (who with his brother, Wolf, gave $16-million), there by the sushi...Murray Koffler, founder of Shoppers Drug Mart and co-founder of Four Seasons Hotels, a man who has given away $50-million in his lifetime, $10-million to Mount Sinai alone, over by the wall. ...Hospital board chairman Lawrence Bloomberg, former First Marathon investment kingpin, and foundation chairman Eddie Sonshine, founder of RioCan Real Estate Investment Trust, perfecting their smile'n'scowl fundraising act (Eddie smiles, Larry scowls)...

But when Don Low gets up to speak, everyone forgets what the other experts have said.

"We will experience a pandemic in influenza," Dr. Low is telling the crowd. "We will not prevent or control a pandemic." As soon as he says it, he has all their attention.

Dr. Low is a phenomenon — thin, bald, grey, slight, a perpetual-motion microbiologist, Toronto's own Dr. McGerm. He rose to widespread public prominence during the SARS crisis, when he became the most reassuring face on TV. Ever since, he has been the media's favourite expert every time there's a viral outbreak of unknown origin — which happens four or five times a year.

In addition to being the chief of microbiology at Mount Sinai, Dr. Low supervises 70 laboratory workers and 18,000 square feet of space, serious acreage in lab land.

He's also medical director of the Ontario government's public-health laboratories and a professor at the University of Toronto, and has five other clinical, research and teaching posts, and 19 other current appointments. His CV is 132 pages long.

He has not one but two BlackBerrys (one for the hospital, one for government), and a pager, and a cellphone: He has so many cubes and boxes and gadgets hanging from his belt he could be a munitions specialist for the Queen's Own Rifles. He often starts the day with a television appearance or two, followed by six meetings before lunch, three more meetings and interviews in the afternoon, and a speech about pandemic influenza after dinner.

Dr. Low doesn't like what he imagines when he thinks about avian flu, and he thinks about it every day. So far, roughly half the people who have contracted bird flu have died from it. Early estimates say 11,000 to 58,000 people could die in Canada.

"Impact's gonna depend on two things," Dr. Low says. "How infectious is it? Is it going to be like SARS, and easily brought under control?" (Easily? That was easy?) "And two, how virulent will it be?"

Then there is oseltamivir, known as Tamiflu in the trade, one of two antiviral agents that can mute or even prevent avian flu, and its attendant ethical problems: "Who do you give Tamiflu to? Is it your first-line medical workers? Politicians? Police? You could argue that the people in the ICU, they shouldn't get it, because they're already sick."

This ability to think clearly about terrifying possibilities is why the entire crowd is hanging on Dr. Low's every word.

"Everyone who works at Mount Sinai during the pandemic will receive Tamiflu as a prophylactic," he says. But then he adds that "it might be that there is just not enough of the drug available."

All of a sudden, hands start shooting up like exclamation points.

One father wants to know if he should buy a $70 respirator from Home Depot for his asthmatic kids; a woman asks how much she should stockpile. Gradually, a fine, almost invisible mist of concern rises in the auditorium.

As Dr. Low says, everyone's greatest concern at the hospital during SARS was "taking it home to their families. And that's going to be one of the things in a pandemic."

If you thought the recent rioting in France was bad, wait until there's not enough Tamiflu to go around in a pandemic.

***

In a hospital, things can be right and wrong and true and not true at exactly the same time, for exactly the same reasons. Up here on the 18th floor, for instance, next to the intensive-care ward, a place where people go to recover or die but seldom anything in between, Tom Stewart, the director of critical care at Mount Sinai and the University Health Network, is trying to decide whether to prescribe an anti-sepsis drug called Xigris that costs nearly $11,000 for one 96-hour course of treatment — even though the patient, an old man, is likely to die anyway.

What should he do? As an administrator, under constant pressure to cut costs and maintain patient flow and free up beds, he should not prescribe the drug. As a humane doctor who has confidence in science, he will. And as a born-again Christian, who believes in God's will and the power of faith?

He's an interesting man.

This is why the hospital is an ongoing argument, a daily debate, a form of incessant intellectual triage: This diagnosis or that one? Spend money here, or there?

Everyone has an opinion on what a hospital like Mount Sinai is doing and what it isn't doing, what it needs to do and what it ought not to do. Sometimes the entire health-care system seems like a swarm of peeves and temper, beneath which a few stubborn souls go about saving lives regardless.

There are specialists who operate private clinics who insist Canada can't afford high-end, publicly funded hospitals such as Mount Sinai. Others say those surgeons are self-serving wannabe Americans. There are private-practice doctors who say Mount Sinai's an ivory tower that needs to re-gear itself to the clinical needs of the population. There are Mount Sinai researchers, such as Katherine Siminovitch, who counter that "if we'd put money into looking after patients rather than research 100 years ago, patients with polio would still be in iron lungs."

None of it seems to get Tom Stewart down: ICU doctors are the calmest of all. Up here on the top floor of the hospital, the choices are clearer. The patients in the unit look like they are feeding the swarm of machines attached to them rather than the other way around.

One morning as we leave the ward, Dr. Stewart says, "So. What do you think?"

"It makes me realize how many different things can carry you off."

"But you know what?" he replies. "It's all luck."

Maybe he's right. Only early in the morning and again late at night, before everyone arrives and after everyone has left (save for the patients and the night nurses and the cleaners and a few stubborn women who refuse to leave the bedsides of ailing children or husbands or mothers) does the hospital let its guard down, and appear for what it actually is — a slim net over a dark river, trying to catch souls being swept from one side to the other.

***

By the second week of September, Lindsay Bastead, 25, of Hillsburgh, Ont., was warming to the experience of being pregnant. Her first attempt had ended in a miscarriage — but so early on in the pregnancy that "we didn't have a chance to get happy," as Will Delill, her partner, put it. Ms. Bastead is blond and shy, a country girl; Mr. Delill is older, 37 and a salesman, and did most of their talking. But in April she discovered she was pregnant again.

She was still at work in September — at Respan Products Inc. in Erin, outside Toronto, manufacturing respiratory gear — when she felt something give. Her cervix was dilated three centimetres. The local hospital put her on a stretcher and sent an ambulance careening downtown to the high-risk pregnancy unit at Mount Sinai, whose history of obstetrical care dates from its founding in 1923 as a maternity service for Jewish women. (Last year, the hospital delivered 7,272 babies.)

When Ms. Bastead arrived, a doctor named Greg Ryan took time out from his regular specialty — astonishing invasive fetal procedures, such as inserting bladder and heart shunts into fetuses in utero — to turn her upside down. Then he put a stitch in her cervix to keep her baby inside. It was low-tech, but it seemed to work.

Now, it's two weeks later, and Ms. Bastead has gone into labour anyway. Her cervix is fully dilated, even with the stitch. The baby wants out.

Her labour lasts all of 15 minutes. A boy. He doesn't look much like a 40-week full-term infant. Why would he? The pregnancy has lasted only 24 weeks and five days; the baby wasn't due for three more months.

But he's here. His name is Zachary. He weighs 700 grams. He's a bruiser next to the smallest babies that have survived Mount Sinai's neonatal intensive-care ward, tiny handfuls that tip in at 465 grams — "four sticks of butter," as the nurses like to say.

But will he live? And if he lives, does he have anywhere close to an even chance of being a normal child?

Was it worth saving him?

***

In a haphazard meeting room on the hospital's 14th floor, even as Don Low wows and cows the governors four floors above, Mount Sinai's executive committee on pandemic preparedness — the bird flu gang — has run smack into another brick wall.

Even Leslie Vincent is frightened by the possibilities of the pandemic — which is frightening all on its own.

Hospitals are grave places, after all, and Leslie Vincent has worked in them (as a cancer nurse, no less) for 30 years, ever since she began her nursing studies at McGill University at the age of 16. "When you're a nurse," Ms. Vincent says, "and you're helping someone who's dying to get in and out of bed every day, you feel their weakness. You experience them getting weaker every day."

But these difficulties never stop her. She can't change the fact that people die, but she can do something about how they die. This approach had helped her to the top of Mount Sinai, where she's senior vice-president of nursing — 1,200 employees, a budget of $115-million, a salary pushing a quarter of a million dollars a year. Not that the money matters that much to her: She still brings her lunch to work. She is still the chief nurse of the hospital.

During the SARS epidemic that made Mount Sinai world-famous, Ms. Vincent had to tell her employees that the hospital was taking in its own staff as SARS patients. It was one of the hardest days of her entire career.

So it is a matter of some note when Leslie Vincent, the salt of the nursing earth, is scared by the thought of a flu pandemic. The problem is that the bird flu is so confounding, she's not sure this time any of them can make a difference.

It's not just the million practical details of preparing a hospital for an inevitable pandemic — whether there are enough ventilators (probably not), how the infected should be admitted (a flow-chart job no one wants), the gruesome issue of morgue overflow, or even the basic question of how to decide when a pandemic has actually begun.

Susan Poutanen, a microbiologist and infectious-disease consultant who is the vice-chairman of the flu committee, reminds everyone that they have already decided that rather than "relying on the Ministry of Health's stockpiles of Tamiflu, given the quantity that would be available to us from the ministry, it would be prudent for us to consider stockpiling our own" — i.e., the government's 12.4 million doses, which would treat a million people, aren't enough, so it's every hospital, business and essential service for itself.

It's a reasonable precaution: If hospital workers get sick, we're all finished.

So the committee plans to distribute the pills, as a prophylaxis to prevent the disease, to everyone in the hospital — patients possibly included. Still, to be even 80 per cent effective, Tamiflu has to be taken every day through the first and second "waves" of the infection — six to 12 weeks or longer.

Ms. Vincent, ever rational, is laying out the cost scenarios. The current retail cost of Tamiflu is $4.20 a pill. Roche, the Swiss manufacturer, will let the hospital stockpile it for $2.50. Over the course of 90 days for the 5,000 people associated with Mount Sinai, that's just north of $1-million. If she includes patients — a move Dr. Low opposes, which the committee is still debating — the number rises to more than $4-million.

But the cost is only the white picket fence at the bottom of the garden pathway that leads up to the real house of horrors.

Is it even a good idea for everyone to be on Tamiflu? Some studies show that the H5N1 virus (the avian form of influenza) can develop resistance. "Is there any modelling" — this is Tony Mazzulli, a microbiologist sitting at the end of the table — "of what would happen when that many people then stop taking the drug? Are you going to extend the period of the influenza?"

Allison McGeer's voice squawks out of a speaker in the middle of the table. Dr. McGeer is an infectious-disease expert at the hospital, as famous as Dr. Low: She actually contracted SARS working in the hospital. She's at the airport, waiting for a plane. Her opinion, along with Dr. Low's, is the group's gold standard.

"I think if...a substantial proportion of the community is taking prophylactic antibiotics, then, yeah, there's a significant risk that we will simply delay the onset," she says.

In other words, even if we all take Tamiflu, it may not help.

"But at the moment, given what the supply is gonna be, and looking at a pandemic in the next two or three years, we're not going to have nearly enough Tamiflu to have that effect."

Silence. Dr. McGeer speaks again.

"If everybody in the population takes it, in Canada but not elsewhere, then maybe all that will happen is that the first wave will happen here when we come off prophylaxis. Then you're just praying that what we're doing is holding until vaccine is available. But I don't think we're realistically anywhere close to that."

Every time someone at the table speaks, the depressing complexity of the Tamiflu problem increases galactically. Will the provincial drug plan pay for it, at $500 a citizen? And how should the hospital dispense it — daily, in a week's worth of pills, or three months' worth all at once?

"The issue in giving out a month or three months' supply," Howard Ovens, the hospital's director of emergency medicine, says, "is people can sell it. Or — 'I lost my prescription!' We'd have to probably tell people if they lose it, we'll give 'em a scrip and they can go to a pharmacy and buy some more."

"Not that it will be available," Susan Poutanen counters.

Dr. Mazzulli thinks daily dispensation is the only answer. "I thought the whole point is to keep them healthy so they can come to work." If everyone gets their daily pill ration at work, "that would guarantee that they're taking it" — and that they'd be working.

"But the logistics of dispensing it daily... everybody would be on duty giving out the pills. That won't work."

"What Don Low is suggesting is what some hospitals did with SARS — change our ID badges to a barcode-reading badge that we could also use to determine who we're distributing what to.

"But then in SARS we had the problem that 10 per cent of the staff daily forgot their name tags."

All this just to figure out how to hand out the damn pills. The hospital has yet to order them. And the committee is only just coming to the most incendiary question of all.

***

By the time Jay Wunder gets to Don Townshend on his consulting rounds, it's 1 o'clock in the afternoon. He is the 14th patient Dr. Wunder has seen today, but Mr. Townshend is used to waiting. He complained to his family doctor in Prince Edward Island about the pain in his right arm for nearly 10 years. Just tendinitis, his family doctor insisted. It was diagnosed last April as malignant cancer. By that time he hadn't been able to feel his middle finger for nearly a year.

Mr. Townshend and his wife, Dianne, have come to Toronto to have the tumour surgically removed. To their surprise, they love the city. Mr. Townshend likes Dr. Wunder too, the way he and the hospital brim with technical sophistication. They waited for weeks for an MRI in the Maritimes, and then it had to be redone. Dr. Wunder orders up a fresh set of images this very afternoon. Once you're in the system, things move fast. It's getting in that's hard.

Dr. Wunder is perfectly named, one of Mount Sinai's triple-threat doctors — surgeon, researcher and teacher. At 43, he's tall, fit, handsome, brilliant, boyish, renowned for sending e-mail messages at 3 a.m. and working all the next day. He never actually stops moving: Even talking to Don Townshend in the consulting room, he dances and twists his long frame around like a teenager who needs to pee.

If you ask Dr. Wunder to explain his subspecialty, osteosarcomas, he simply says, "Terry Fox" — referring to the rare kind of musculoskeletal cancer that took Mr. Fox's leg and eventually his life. "When Terry Fox was treated, 90 per cent died," Dr. Wunder always adds. "Now about 75 to 80 per cent stay around."

Only 5 per cent lose limbs today, whereas everyone did in Mr. Fox's day. There are those who question whether Mount Sinai, a publicly funded hospital (it received $238-million from the Ontario government in 2005) should devote so much attention to so rare an affliction, when much greater numbers of people are waiting for more common operations. But you can cure most sarcomas — one reason Dr. Wunder likes his specialty.

Mr. Townshend hasn't been able to straighten his right arm for more than a year — a problem, as he's a mechanic in farm country outside Charlottetown. The tumour has grown around the nerve and an artery and the bone in his upper right arm: Dr. Wunder can't remove the tumour without removing everything else.

It might be possible to save the arm. "But if that second nerve is involved in that tumour, then you're gonna wake up with an amputation," Dr. Wunder warns.

Mr. Townshend looks at his wife. He would like to save his arm, if possible. He likes doing things with his hands — such as doing up his own pants. "Even as the arm is," he tells Dr. Wunder, his accent curving all the way in from the Maritimes, 'I've had a good summer. I've done lots of things. So even as a crippled-up arm, it's been pretty handy to me."

Three forms to sign, and it's set: Mr. Townshend and his wife are to show up for pre-admitting tomorrow at 2:30. The operation will start first thing the next morning. The day after that, he'll know if he still has an arm, much less cancer.

Whereupon the good doctor strides into the consulting room next door to look at the images (they're all computerized at Mount Sinai) of his next patient, a young man he soon deduces has non-Hodgkin's lymphoma. That's another cancer, although in this case probably a survivable variety.

"Does he know anything?" Dr. Wunder asks a resident before going in to break the news.

"No," the resident says, and then he stops. "The mother wants to know if it's shin splints."

***

Finally, at last, as if she were defusing a bomb with her mind and no hands, Susan Poutanen drops the big one on the bird-flu meeting. She always speaks from memory, quickly, clearly, in complete sentences — a big medical brain.

"If we can get all our health-care workers on prophylaxis," she says, "what about their families? And should we? And what are the reasons for offering it to families? Obviously it should not just be because of privilege, being associated with a health-care worker."

It's sunny outside, a gorgeous fall day, but everyone is riveted. The controversial suggestion was originally made by Kerry Bouman, Mount Sinai's ethicist, who argued that the hospital is obligated to keep its workers available and healthy for the public, and so has to protect them from infection at home by medicating their families.

The committee was already planning on giving prophylactic Tamiflu to physicians and nurses, associated staff, medical and nursing students, researchers, the hospital's foundation, the board of directors and volunteers, for a rough total of 5,000. But giving it to their families, too? That could be 15,000 more people.

And what about the board of governors, to whom the committee has considered making the drug available at a price?

There are nearly 600 governors of the hospital — more governors than there are beds. Should they get it, even at a price, if your children don't?

On the other hand, if you gave a million dollars to your favourite hospital, and served on its board or its auxiliary, selflessly and tirelessly, wouldn't you think, if only for a moment, that at least your grandchildren deserve the drug? That way they might live to become donors too.

Logically, you keep the doctors and nurses alive, so they can minister to others. Emotionally, you protect your loved ones. But this is a group of scientists, trying to be rational and civic-minded. They're already aware of large corporations known to be stockpiling their own Tamiflu.

Dr. Mazzulli thinks that this is medically retarded. "In fact," he says, "the family's risk is less ..... because health-care workers will already be on prophylaxis."

"Well, what about the diversion issue?" This is Dr. Ovens again. "I would think one of the highest risks is for workers here at the hospital to divert and not take their pills, if they have a relative they perceive to be at higher risk than themselves. A kid with asthma, a spouse." Hence a vote for family coverage.

"I think it has the potential for disaster," Dr. Mazzulli agrees. "People splitting the pills, saying, 'A little's good enough, you take a little, I'll take a little, he takes a little.'"

"But the most obvious reason to protect families" Dr. Ovens says, "is that if you have an ill family member who's a dependent, then you won't come to work. Because you'll be home looking after your family member. That will contribute to the absentee rate."

"There's another argument that links very nicely," says David Cox, from the human-resources department. He's strongly in favour of giving Tamiflu to family members of hospital workers — all hospital workers, not just front-line medical types.

"It's a morale issue. The last thing health-care workers want to do is also worry about whether their families are gonna get sick, whatever part of the hospital you work in. So I think it makes ethical sense to be provided to the families.

"Where I think we're going to have problems is, where do you draw the line on what is family? I mean, are we going to ask people to prove that 'grandma and granddad are actually living in the house with us,' which they may indeed be — in which case, for example, I would say they would qualify."

"I could almost ask my niece and a baby and my mom and everybody else to move in because I'm single," a woman pipes in. "So I could say, 'Get in here and stay here.'." But in the end, the committee holds off approving Tamiflu for families. The problem is other hospitals in the city. "The first hospital of major significance that breaks ranks — and it's almost guaranteed this will happen," Mr. Cox adds, "and decides to supply it to their families is going to create a huge dilemma for every other hospital."

During SARS, it was hospital workers who brought the sickness home, and who were ostracized: People gave a nurse in fatigues a wide berth on the street. "But," Susan Poutanen points out, "this time it's the whole community."

"Imagine," Leslie Vincent says, "almost a reverse ostracism. People in society who receive prophylaxis, and those who don't. How will society feel that some people have priority and others don't?"

It's going to be ugly.

***

Grief is what a visitor sees most steadily, and also most unexpectedly — a woman crying quietly by the elevator, another as she tries to make a baby suck, some while talking, others while walking. Some days, unrestrained sobs bounce down the corridors of the hospital — those endless tubes, strewn with coveted blood-pressure machines and abandoned chemo chairs and yellow soiled linen hampers and gurneys and food-tray racks, all on wheels though they rarely move — like hopeful mutes in a Pinter play.

Or there is this afternoon in the Marvelle Koffler Breast Centre, where K., as we'll call her, is submitting to her first bout of chemotherapy. She's in her 60s: She had a lumpectomy 18 years ago, survived, raised her children, lived her life and had almost come to take her annual mammograms for granted again. Then, in June, it came back. Eighteen years, same side, this time a mastectomy. Of course she is determined to beat it — a trim, intelligent women, neatly dressed in white sneakers, black pants, a red and white striped shirt, a sleeveless vest.

She is sitting in a thick, padded, blue chemo chair, waiting while the nurse in the blue smock finds a vein for the adriamycin and the cyclophosphate, the magical compounds that will, with luck, drive the cancer away. "You have good veins," the nurse says.

"Oh," K. says, her voice flying up lightly to the ceiling, "I have good veins. I have good something!" She's nervous, can't bear herself with the cancer in her, and so chatters away: She wants to try the medical marijuana, she has already bought a wig for when her hair falls out, she was a teacher of languages (she speaks five). Her husband sits behind her, smiling, shaking his head at this alertness of hers he knows so well.

Now, she is talking about her childhood, how during the last months of the war in March of 1945, when she was a girl of 5, her mother and father hid her and her siblings in the mountains near their home in Czechoslovakia. The defeated Nazis were shooting Jews, even as the Reich retreated. "We never took our clothes off for seven months," she says.

Her parents are dead now, of course, but lately, since the cancer came back so late and unexpectedly, she has been thinking of them. "I talk to them," she says, and there is that quick moment of sheen in her eyes you see so much in a hospital. No one pays it much attention. "Because they protected me before, took care of me.

"So I think, 'Do your job now. Protect me.'"

Ian Brown is a feature writer for The Globe and Mail