Document ZJ6zJa6jjQDBwYpGM2KNJGen8

No. 73 November / December 1976 HEALTH / PAC _ Health BULLETIN Policy Advisory Center 1 Swine Flu: PLAY IT AGAIN, UNCLE SAM. The nation- wide vaccination program, conceived in haste and fear, became locked in as public policy despite the better second thoughts of many of its scientific proponents. BOO! 7 Notes From NYC's Fiscal Crisis: FIGHTING OVER THE PIECES. Two new public hospitals in the Bronx get caught in the squeeze of fiscal politics. 21 Vital Signs 24 Cumulative Index December (31, 1976) Swine Flu PALGAAYI INT, The swine flu vaccine program is the most recent chapter in the larger story of the UNCLE SAM failure to provide adequate health care for the American people. The main theme is a familiar one: the federal government's inability to intelligently consider and reason- ably implement an effective public health program against a backdrop of massive expenditures for hospital oriented - acute care and minimal expenditures on preventive and outpatient care. Bill Plympton At the center of the action are the nation's medical scientists and their role in the development and implementation of govern- ment policy. Based on real fears of a world - wide " killer " flu outbreak, these scientists, with their activist medical orien- tation, prematurely recommended a massive program whose implications they barely comprehended. In so doing they took an active role in the decision - making process, despite assertions by many of them that they are " just scientists " and technical advisors, outside the political process. Their presenta- tion of the facts and their inability or unwillingness to explore the ambiguities and uncertainties in their knowledge led the Executive branch to rush into a program that is ill considered - , mistargeted and largely ineffective. Marching in close step behind these scientists came the various private interests -especially large drug companies - who had played a smaller role in initiating the program but stood to gain substantially from its implementation. Once these interests had thrown their full corporate weight behind a mass innoculation program, it became virtually impossible to reconsider it. This latter point is all the more poignant since many of the growing doubts about the effectiveness of the program have been voiced by the very scientists who initially championed it. The current federal strategy for protecting Americans against the swine flu is: (a) vaccination of " high - risk " people with a bivalent (virus two -) vaccine that seeks to protect them against both swine flu and ordinary Victoria flu viruses and (b) vaccina- tion of all other Americans eighteen years and older against swine flu virus alone. On the basis of the available evidence there is no reason to dispute the vaccination of high - risk people. High - risk persons are those who would have a significant chance of dying if they contracted influenza. They fall into two categories: those over 65 years of age and those with serious, chronic diseases, including: pulmonary disorders, such as emphysema and severe asthma; heart disorders, especially mitral stenosis; meta- bolic disorders, like diabetes and cystic fibrosis; certain kidney disorders; and deficiencies of the immune systems. Forty million Americans, one fifth - of the popula- tion, fall into these two categories and account for well over 80 percent of all deaths associated with recent influenza epidemics. While the Federal government's strategy of vaccinating high - risk persons may be STATEMENT REQUIRED BY THE ACT OF AUGUST 12, 1970; SECTION 3685, TITLE 39, UNITED STATES CODE, SHOWING THE OWNERSHIP, MANAGEMENT AND CIRCULATION OF THE HEALTH / PAC BULLETIN. 1. Title of Publication: Health / PAC BULLETIN. 2. Date of Filing: September 30, 1976. 3. Frequency of issue: Bi monthly - . 3A. No. of issues published annually: Six. * 3B. Annual subscription price: student $ 8.00; regular 10.00 $; institutional $ 20.00. 4. Office of publication: 17 Murray Street, New York, New York 10007. 5. General business office of publishers: 17 Murray Street, New York, New York 10007. 6. Publisher: Health Policy Advisory Center, Inc.; Editor: Ronda Kotelchuck, c o / Health / PAC, 17 Murray St., N.Y., N.Y. 10007; Managing Editor: Barbara Caress, c / o Health / PAC, 17 Murray St., N.Y., N.Y. 10007. 7. Owner: (If owned by a corporation, its name and address must be stated and also immediately thereunder the names and addresses of stockholders owning or holding 1 percent or more of total amount of stock. If not owned by a corporation, the names and addresses of the individual owners must be given. If owned by a partnership or other unincorporated firm, its name and address, as well as that of each individual must be given.) Private, profit non - membership corporation: Health Policy Advisory Center, 17 Murray Street, New York, N.Y. 10007. Members: Barbara Caress, Oliver Fein, Steven London, David Kotelchuck, Ronda Kotelchuck, 2 Kenneth Rosenberg, Elinor Blake, Tom Bodenheimer. 8. Known bondholders, mortgagees, and other security holders owning or holding 1 percent or more of total amount of bonds, mortgages or other securities: None. 9. For completion by nonprofit organizations authorized to mail at special rates (Section 132, 122, PSM) The purpose, function, and nonprofit status of this organization and the exempt status for Federal Income tax purposes: Have not changed during preceding 12 months. 10. Extent and nature of circulation: average number of copies each issue during preceding 12 months: total number of copies printed (net press run): 6,000; paid circulation: (1) sales through dealers and carriers, street vendors and counter sales: 0; (2) mail subscriptions: 3,050; total paid circulation: 3,050; free distribution by mail, carrier or other means, samples, complimentary, and other free copies: 306; total distribution: 3,356; copies not distributed: (1) office use, left over, unaccounted, spoiled after printing 2,644; (2) returns from news agents: 0; total: 6,000. Actual number of copies of single issue published nearest to filing date: Total number of copies printed (net press run): 6,000; paid circulation: (1) sales through dealers and carriers, street vendors and counter sales: 0; (2) mail subscriptions: 2,827; total paid circulation: 2,827; free distribution by mail, carrier or other means, samples, complimentary, and other free copies: 301; total distribution: 3,128; copies not distributed: (1) office use, left over, unaccounted, spoiled after printing: 2,872; (2) returns from news agents: 0; total: 6,000. I certify that the statements made by me above are correct and complete. (signed) Ronda Kotelchuck, Editor. sensible, there is considerable reason to oppose the decision to vaccinate non high- - risk people. Vaccination of the entire US population represents a huge expenditure of public health resources which at best could prevent non fatal - illness in some. More like- ly, however, the program will divert scarce public health resources with no significant effect at all. The vaccination of non high - - risk people was premised on similarities between the new swine flu virus and the virus that many scientists believe caused the great flu pandemic (world - wide epidemic) of 1918, an association that is now largely discredited. The plan for mass vaccination of the entire population has come under such intensive public attack that some states are already effectively giving it up. Massachu- setts, for example, has publicly stated that the vaccination of high - risk persons is their first priority and only after this has substantially been accomplished will they begin to vaccinate others. Given the slowness of the implementation of the mass vaccination program nationally, few non- high - risk persons are likely to be vaccinated in Massachusetts this year. INFLUENZA AT FORT DIX When, in January, 1976, soldiers returned to Fort Dix from their Christmas holidays, they brought with them the usual assortment of sniffles, sneezes, runny noses and coughs. Army doctors assumed they were seeing the usual adenoviruses (common cold viruses), some of which were severe enough to require hospitalization. They gave little thought to influenza because every Army influenza recruit receives a heavy dose of influenza vaccine upon beginning basic training and is revaccinated each year with whatever influenza strains are prevalent that year. Colonel Joseph Bartley, chief of preven- tive medicine at Fort Dix, called the local county health officer to warn him that the adenoviruses might spread to the nearby 1918 The influenza pandemic of 1918 oc- curred in two major waves. The first was in the winter and spring of 1917-18 and was characterized by high morbidity 50 (% of the people in the world got it) and low fatality rates. The second wave started at Fort Devens, Massachusetts on Septem- ber 12, 1918 and involved almost the entire world in a very short time. Its spread was bizarre: it was detected on the same day in Boston and Bombay but it did not occur in New York until three weeks later. It did not affect those who had been ill the previous winter and spring but its effect on everyone else was devastating. It may well have killed more people in a short space of time than any other disaster in the history of the world. In all, about 20 million people died, including 500,000 Americans, in six to eight weeks. A total of 500 million people are estimated to have been stricken by the disease in the same period. " The number of fatalities at the height of the outbreak in Boston were 175; in New York City, 600 to 700; and in Philadelphia, 1,700 per day.... The impact of this pandemic was as great as that of the plague in London, which killed about 2 percent of the population per month.'' (1) Much of the 1918 mortality occurred among young adults, who rarely die from flu, rather than such typical victims of flu epidemics as the elderly and chronically ill. In many cases, young persons became ill in the morning and died that night, often without any chance to get medical attention. (2) See References pages 19, 20 a civilian population. The county health officer in turn contacted Dr. Martin Goldfield, director of public health laboratories for New Published by the Health Advisory Center, 17 Murray Street, New York, N.Y. 10007. Telephone (212) 267-8890. The Health / PAC BULLETIN is published 6 times per year: Jan./Feb., Mar./Apr., May June /, July / Aug., Sept./Oct. and Nov./Dec. Special reports are issued during the year. Yearly subscriptions: $ 8 students, $ 10 other individuals, $ 20 institutions. Second - class postage paid at New York, N.Y. Subscriptions, changes of address and other correspondence should be mailed to the above address. New York staff: Barbara Caress, Oliver Fein, David Kotelchuck, Ronda Kotelchuck, Steven London and Ken Rosenberg. Associates: Robb Burlage, Morgantown, W. Va.; Constance Bloomfield, Desmond Callan, Nancy Jervis, Kenneth Kimmerling, Louise Lander, Howard Levy, Marsha Love, New York City; Vicki Cooper, Chicago; Barbara Ehrenreich, John Ehrenreich, Long Island; Robin Baker, Elinor Blake, Judy Carnoy, Dan Feshbach, Carol Mermey, Ellen Shaffer, San Francisco; Susan Reverby, Boston, Mass. BULLETIN illustrated by Bill Plympton. Health Policy Advisory Center, Inc. 1976. 3 Jersey, who said that the outbreak sounded more like influenza than an adenovirus. He suggested that cultures from the affected soldiers be checked by the state lab for the influenza type predominant at the moment, A Victoria/ /7 5 (so named because it is a Type A influenza strain that was first identified in Victoria, Australia in 1975). Goldfield was right: Fort Dix was having a flu epidemic. Most of the nineteen cases for which samples were sent to the New Jersey labs on January 29 contained the Victoria flu, but four samples were unusual strains of Type A influenza that could not be identified. The unknowns were sent to Atlanta, Georgia to the Center for Disease Control (CDC), a branch of the Public Health Service of the US that if he missed more than three days of basic training, however, he would have to repeat it all, so he joined his company on a seven mile " forced march " in the snow. Lewis collapsed before the end of the march and was dead on arrival at the base hospital. Most experts, including Colonel Bartley, think Lewis would have lived if he had stayed in bed instead of going on the march. Immediately a large - scale screening was implemented at Fort Dix and in the surrounding community. A New / Jersey / 76 was isolated in five cases, including that of Lewis. In another eight cases there was clear Department of of Health Health,, Education and Welfare (DHEW). To the amazement of the CDC staff, they discovered, on February 13, that this unusual Fort Dix virus was similar to one of the first viruses that had ever been To the amazement of CDC, they discovered that this unusual Fort Dix virus was similar to isolated, in the 1930s. This virus had early been identified as very similar to a virus common in pigs (hence the name " swine flu " virus). What is more, one of the first viruses ever isolated. in most locations investigated throughout the world, survivors of the 1918 flu pandemic had antibodies to to this virus, leading scientists to conclude that the 1918 pandemic had been caused by swine flu virus. CDC labelled this new virus strain A New / Jersey / 76 (Type A virus strain discovered in New Jersey in 1976) and alerted Army doctors to the possibilities of a " killer " virus outbreak like that of 1918. CDC was particularly concerned because the swine flu virus at Fort Dix had been evidence of infection by A New / Jersey / 76 as determined by an increase in antibody levels following the second of two blood tests several weeks apart. In another 500 cases high levels of antibodies to swine flu virus were found after a single blood test; these cases were concentrated in the same companies as the positively identified cases, although many of these soldiers had not been sick. spread from one person to another, apparently because of a recent genetic mutation of the virus. Virologists had seen CDC ORCHESTRATES A RESPONSE The discovery of swine flu virus at Fort Dix swine flu in people in direct contact with and Lewis'death prompted CDC to call an pigs, but they had never before seen swine urgent meeting on February 14. Representa- flu spread from person to person. Their tives attended from the Army, the State of assumption that 1918 was caused by a swine flu that spread from person to person raised the specter of an epidemic of major proportions. A SOLDIER DIES New Jersey and three involved branches of the New Public Health Service: CDC; the Food and Drug Administration (FDA), represent- ed by Its Bureau of Biologics; and the National Institutes of Health (NIH), repre- sented by the National Institute of Allergy On February 4, the same day CDC and Infectious Diseases. All parties agreed received initial samples from Fort Dix, Private David Lewis died of viral pneumonia at Fort Dix. Lewis had had a moderately severe flu like - illness and was told by Army 4 doctors to stay in bed for 48 hours. He knew to a serious investigation of the swine flu situation at Fort Dix and a search for cases elsewhere. On February 19, CDC made the first public announcement that a new flu virus had been discovered. The official press release said The day after the CDC announcement, the nothing about 1918; under questioning, Bureau of Biologics, the primary FDA however, Dr. H. Bruce Dull, Assistant agency responsible for checking the safety Director of CDC, noted the similarity and efficacy of vaccines, sponsored a between the flu strains. The next day media workshop for university, government and reports throughout the United States featur- industry scientists in preparation for a ed stories about Fort Dix and the " specter of possible crash mass vaccination campaign. 1918. " Reporters quickly sought out survi- They set April 1 as the date by which a vors of the 1918 pandemic and recorded their decision would have to be made if a mass reminiscences in numerous media features. campaign were to be carried out in time to The predictable rise in public fears paved the prepare for a possible autumn outbreak. way for federal action. Rushing against this deadline, medical a scientists and public health officials searched Was 1918 Swine Flu? aggressively for new evidence of the disease. They found none. No new cases were found In recent years the theory that the 1918 at Fort Dix or anywhere else in the US or the rest of the world. pandemic was caused by the swine influenza virus has also come under attack. Three NIH scientists, including Dr. J. Anthony Morris and 1976 Nobel prize winner D. Carleton Gajdusek, reported in a Nevertheless, in a March 13 " action memo, " Dr. David Sencer, Director of CDC, recommended a mass vaccination program for all Americans at a total cost of $ 135 million. He noted that " the Administration 1969 Science article the details of a study of an isolated Pacific island which had been exposed to only one twentieth century flu epidemic, a late outbreak of the 1918 pandemic. They measured antibodies in the inhabitants'blood and found much can tolerate unnecessary health expendi- tures better than it can tolerate unnecessary . death and illness, particularly if a flu pandemic should occur. " Sencer's memo was issued on his own initiative. He failed even to consult members higher antibody levels to PR / 8 influenza virus than to swine flu virus. PR / 8 is an A type - virus that has very different surface antigens (protein subunits) than swine flu. The study concludes, " Our results indicate that the virus circulating in the 1918 pandemic era was more closely related to human type A strains circulating in the middle 1930s than to other known of the CDC's own Advisory Committee of Immunization Practices before sending the memo to higher - ups in the Ford Administra- tion (perhaps because the Committee at its March 10 meeting had refrained from calling for such a program, recommending only that planning for such an eventuality begin). AN EPIDEMIC IS CREATED influenza virus strains, including the virus of swine influenza. " (1) One reason scientists have so long accepted findings that the 1918 pandemic was swine flu, according to the same article, is that almost all data were gathered from urban populations. " Al- though antibody to swine influenza occurs very infrequently after a single infection by the PR / 8 strain of influenza virus, antibody develops against both swine and human strains of influenza after repeated im- munization with the PR / 8 _ strain. " Antibodies to swine flu virus may have developed simply because of " the broad- ening effect of cumulative infections with human type A strains. " (2) See References pages 19, 20 eS On March 22, DHEW officials took the memo to the President. Ford, never known for quick, decisive action, except for the deadly Mayaguez incident, called a meeting with thirty prominent medical scientists within 48 hours. The scientists, led by Jonas Salk and Albert Sabin, both of polio vaccine - fame, and vaccine researchers researchers Edwin Kilbourne of Mount Sinai Medical School and Fred Davenport of the University of Michigan, recommended a nationwide vac- cination program. Literally within minutes of the panel's recommendation, President Ford called a press conference to announce the program. " This virus is very similar to the one that caused a widespread and very deadly epidemic late in the First World War, " the President said. " Some older Americans 5 today will remember that 548,000 people died in this country during that tragic period. " The only way to prevent a recurrence, he concluded, was to vaccinate " every man, woman and child " in America. In the aftermath of President Ford's dramatic announcement, with little serious debate, Congress enacted the program. Symbolically, the date was April 12, thirty - first anniversary of Franklin Roose- velt's death and the day, exactly ten years later, that successful results of the polio vaccine trials were first announced publicly. Congress appropriated the entire $ 135 million requested for the program: * $ 100 million for purchase of 200 million doses of flu vaccine from four drug companies (Merck, Sharp and Dohme; Merrell National - ; Wyeth; and Parke - Davis); * $ 26 million in project grants as seed money to state and local governments to develop mass immunization programs; $ 4 million to the National Institute of Allergy and Infectious Diseases to expand research on flu; * $ 3.2 million to the FDA to certify the vaccine; * $ 1.85 mittion to CDC to coordinate the national program. Thus three quarters - of the money went to private, making profit - drug companies. The companies were reimbursed at about 50 a On March 22, the scientists, led by Jonas Salk and Albert Sabin, recommended a nationwide vaccination program. cents per dose, roughly the same cost per dose as in earlier flu vaccination programs. In contrast, administrative expenses were underfunded: only $ 26 million - 13 cents per dose was budgeted for state and local administrative costs. These costs averaged 60 cents per dose during earlier vaccination programs, however - more than four times the budgeted amount. State and local health officials had earlier 6 protested the inadequacy of the proposed administrative funding, but to no avail. They argued that already hard pressed - states could not allocate additional funds for this new program but would be forced to divert money and resources from already under- funded preventive and public health pro- grams like family planning, maternal and child care and tuberculosis and venereal disease surveillance. THE BUBBLE BURSTS Initially the decision to launch the mass vaccination program seemed sensible given the little data available. A new flu strain had been detected, which could be expected to lead to a worldwide outbreak (all previous strains since 1930 had done so). Its virulence was apparently confirmed by Private Lewis ' death and by the virus'resemblance to the strain usually blamed for the 1918 pandemic. Medical scientists believed that they had the capability of preventing an epidemic, given their unprecedented lead time in detecting the virus perhaps - six to twelve months earlier than any previous strain. For such a vaccination program to be effective, they felt, it must include healthy young adults - the group particularly hard hit by the 1918 pandemic - as well as more traditional victims of the flu the - elderly and the chronically ill. The basic medical assumptions behind the program, however however - that that the flu strain threatened a worldwide outbreak and that it was a " killer " virus - were not borne out. During the spring and early summer the fearsome projections of the program's supporters were undermined by an increas- ing accumulation of negative evidence pouring in from many sources and discount- ing the medical rationale for the program. This evidence was persistently discounted or ignored. THE DISEASE DOES NOT SPREAD Despite an intensive search for A New / Jersey / 76, not a single case has been found anywhere in the world since the Fort Dix outbreak. After the first week in which swine flu was detected at Fort Dix, repeated throat washings at the Army base have turned up only the common A Victoria/ /75 . The winter flu season has now passed in the Southern Hemisphere and flu centers there have detected no A New / Jersey / 76. (1) Nor have (Continued on page 10.) DUE TO CLOSED LACK OF FUNDS 1 MUNICIPAL " MUNICIPAL HOSPITAL oo 8. Plympton Notes From NYC's Fiscal Crisis North Central Bronx Hospital Fiasco In the midst of fiscal crisis, New York City's Health and Hospitals Corporation (HHC - the quasi public - parent agency of NYC's public public hospitals) has narrowly avoided forfeiting $ 800,000 to a private hospital. It all began seven years ago when the Bronx's private Montefiore Hospital deeded 73,000 square feet of prime real estate to the City of New York. There was one major hitch: the City was obligated to construct a 412 bed - public hospital on the land, located adjacent to Montefiore. The City agreed to the obligation and further committed itself to a formula whereby Montefiore would receive $ 400,000 (the land's appraised value) if no hospital were built plus $ 400,000 if the city decided not to contract with Montefiore to manage and staff the facility (see BULLETIN Jan./Feb. 1974). Construction of the new facility - to be known as North Central Bronx (NCB) Hospital went according to formula until 1973 when public outcries were heard from Bronx community groups protesting the " giveaway " nature of the arrangement. They argued that giving Montefiore effective control and a guaranteed income from NCB amounted to giving public property to a private institution. They were further angered that NCB's North Bronx location made it all but inaccessible to much of the South Bronx's population. Montefiore and HHC agreed to restudy their plans. Ultimately, however, this re- examination was lost in the shuffle of administrations at both City Hall and the HHC. NCB construction was completed in 1976. Meanwhile, fiscal crisis loomed over the City and the HHC. The future of municipal hospitals in New York was in serious doubt, and by now NCB was seen as a replacement facility for two antiquated Bronx municipal hospitals Morrisania and Fordham. The fiscal crisis also called into question the financial arrangements between HHC 7 and Montefiore concerning operation of NCB. The HHC, for example, backed off its previous commitment to cover any debts incurred by Montefiore for patients without third party - coverage (Medicaid, Medicare or private insurance). A battle of nerves ensued between HHC and Montefiore. In July, NCB opened its doors to everyone but patients; fully staffed and operational, the hospital " functioned " at a cost of $ 2.5 million a month for over three months without admitting anyone. NCB could not admit patients without an operating certificate from the New York State Department of Health. State officials refused to grant such a certificate until the following issues could be resolved: * Where would HHC find the anticipated $ 41.6 million needed to operate NCB annually? The question was a biting one since HHC's expenditures were already running $ 75 million over its budget. * How could the state allow HHC to add 412 hospital beds in a city already thought to contain 5,000 excess beds? Specifically which Bronx hospitals would be eliminated? * Should the HHC sell NCB to Montefiore, thus escaping any operating cost Z responsibility at all? Such a suggestion seemed perfectly rational, to those who sympathized with the call by financial leaders for drastic cutbacks in all city services. Resolving these and lesser issues involved weeks of backroom bargaining among City, State and Montefiore representatives. None seemed especially worried that the entire municipal hospital system was sinking; rather it was as if the officers on the Titanic had fallen into a poker game with the ship and fittings as stakes. Meanwhile aboveboard, the public on the one hand and the worker's unions on the other demanded the hospital's opening. As the media focused on the costs of delay, community groups protested the lack of health care and the largest municipal workers union - DC 37 threatened - citywide action, the HHC filed suit in State Supreme Court to force State officials to issue the operating certificate. On October 14, State Supreme Court Judge Edward Greenfield finally ordered the certificate released and on October 22, with Montefiore agreeing to a trimmed - down affiliation contract, North Central Bronx Hospital admitted its first patient. Disposable Hospital At least two patients are reported to have bled to death in recent weeks at the South Bronx's Lincoln Hospital as a result of cuts in services and battles over its affiliation contracts and administration. The New York Times (November 5, 1976) reported that State Health Department investigators clearly linked the two deaths to inadequate facilities and a shortage of nurses. " Others may have died " as well, according to Robert Whalen, State Health Commissioner. Constructed at a cost of $ 260 million, the 700 bed - Lincoln Hospital has virtually ceased to function as a health care facility - a victim of New York City's byzantine health politics, compounded by severe fiscal crisis. Lincoln's administration was for many years controlled by Ramon Velez, czar of the South Bronx anti poverty - empire. Velez hand picked - Lincoln's administrator, J. Cesar Galarce, as well as numerous other administrative and service personnel. Charges of Galarce's gross incompetence were overlooked by Mayor Beame since Lincoln, cornerstone of the Velez empire, served as bastion against the influence by Herman Badillo, another Puerto Rican politician. Badillo was a Beame opponent in the last mayoral Democratic primary and is a 800 probable opponent in the next. Bill Plympton When Badillo defeated Velez in Septem- ber's primary for the South Bronx congres- sional seat, pressure mounted for Galarce's dismissal. The Health and Hospitals Corpor- ation (HHC) felt obligated to get rid of Galarce. But, like virtually every other recent event involving the public hospitals, firing Galarce became an ugly and complicated matter. Following a perfunctory and obviously pre- ordained investigation, HHC accused Galarce of mismanagement and summarily fired him in late October. Galarce refused to leave. Reports of suspicious fires, gangs running through corridors, and takeover of the administrative offices by Velez's hench- men began to circulate. Badillo called for " the National Guard to stop the reign of terror ". After more than a week of utter chaos, Galarce was finally removed; Lincoln has since been administered from the HHC's downtown Manhattan offices. Despite its obvious problems, however, the new Lincoln remains a plumb to the medical schools and voluntary hospitals whose affiliation agreements provide much of the professional staffs in public hospitals. These private affiliates, feeling the fiscal pinch as well, since where there were four public hospitals in the Bronx, there are now three. Montefiore Hospital is now securely installed at NCB (see above) and Albert Einstein College of Medicine continues its affiliation with the Bronx Municipal Hospital Center. With the closing of Fordham Hospital, however, Einstein has been forced to share affiliation at Lincoln with Fordham's old affiliate, Misericordia Hospital. The only Catholic institution in the mix, Misericordia had actively campaigned for the NCB affiliation but lost out to Montefiore. It then insisted on being given Lincoln as a kind of consolation prize. Einstein balked. Governor Carey and Deputy Mayor John Zuccotti came down on Misericordia's side. HHC's own Board of Directors voted for continuation of the joint affiliation. Finally, Mayor Beame and Governor Carey overruled them and Einstein will be phased out of Lincoln by June, 1977. Amidst all this jockeying, the two deaths. reportedin the emergency room were avoidable according to Lincoln's Director of Surgery, Dr. Francisco Suarez. " There is an excellent chance [of more deaths] unless the real gut problems are resolved, " he said. Despite the deaths - not to mention its investment of $ 260 million - the City seems to regard Lincoln, the only public hospital in the south Bronx, as a disposable item to be used for ammunition in the increasingly heated wars over fiscal politics. PROGNOSIS NEGATIVE: CRISIS IN THE HEALTH CARE SYSTEM edited by David Kotelchuck A NEW HEALTH / PAC anthology of many of the best recent articles from the Health / PAC BULLETIN, as well as important health policy articles from other publications. published by Vintage Books Random ( House). Price $ 2.95 per copy plus 21 postage to: Health / PAC 17 Murray Street New York, New York 10007 Swine Flu hospitalized with A New / Jersey / 76 during the Fort Dix outbreak with ten men (Continued from page 9.) any of the World Health Organization's 96 monitoring stations all over the world ever found New A / Jersey / 76. (A recent case of swine flu in Missouri was documented by increased swine flu antibody level. The lack of spread despite extensive searches among contacts makes it likely that this man's illness was due to the classical pig man - to - swine flu, not the Fort Dix swine flu, which spread from person to person. This was not an example of seeding but another variety of swine flu. This variety's virulence appears to be low judging from the man's relatively mild symptoms.) This absence has important implications because no pandemic of flu has ever occurred without being preceded by at least several local outbreaks in various parts of the world, according to British flu expert Dr. David Tyrell. (2) Tyrell's statement is sup- ported by Dr. W. Charles Cockburn, Director of the Communicable Disease Division of the World Health Organization. Currently none of this " seeding process " is evident. (3) The failure of A New / Jersey / 76 to spread led two researchers to state, in the lead article in Lancet, one of Britain's most respected medical journals, " It seems possible that the outbreak in the U.S.A. was an isolated event and that the virus will not become established in man. " (4) There is a possibility that A New / Jersey / 76 has been detected early in its natural cycle compared to previous strains and that it will " seed " later and strike with full force in the winter of 1977-78. If so, however, a vaccination program this year will have little impact on the seeding process and the whole vaccination program will have to be repeated next autumn, since flu hospitalized with A Victoria/ 7/5 . It conclud- ed that " their illnesses were similar but that A New / Jersey influenza may have been a somewhat milder illness. " (6) In a review article in the July 3 Lancet, the renowned Charles Stuart Harris - summarizes the influ- enza epidemics of the last forty years and concludes: " This experience of pandemic influenza due to a virus of antigenic composition completely different from its precursors thus gives no ground for a belief that the Swine - like virus will behave in an unusually virulent way. Nor can the human population of 1976 be regarded as analogous to that of the Western World of 1918 after 4 years of an exhausting war.'' (7) Even the apparent resemblance of A New / Jersey / 76 to the earlier swine flu strain in laboratory tests is weak evidence for its virulence. (8) A New / Jersey / 76 was identi- fied and typed because it produced the same antibodies as the original swine flu virus- i.e., it has very similar surface antigens. But this similarity sheds no light on the internal antigens, which determine a flu strain's virulence. Many scientists noted, for exam- ple, that flu strains with surface antigens similar to the 1918 flu virus continued to be common around the world until 1928 but during those ten years they rarely killed healthy adults or even produced particularly severe symptoms. Throughout the swine flu controversy much public confusion has arisen from the assumption that a pandemic implies great virulence. This, of course, is not necessarily true: there can be world - wide spread of low virulence - influenzas. So far there is neither evidence of a world - wide swine flu outbreak nor any solid evidence of swine flu virulence. vaccinations give immunity for only six to eight months. NOT A KILLER VIRUS THE VACCINE ITSELF: HOW EFFECTIVE? In recent months another major line of Mounting evidence also casts doubt on criticism of the mass vaccination program whether A New / Jersey / 76 is a killer virus. has developed: that flu vaccines in general Six British volunteers were infected with are not very effective and that they have A New / Jersey / 76 and the mildness of their significant side effects. symptoms led the researchers to conclude Those in government who have been that New A / Jersey / 76 is less virulent in man responsible for carrying out the program, not than A Victor/i a75 ./ (5) A similar result was surprisingly, have been optimistic about the 10 reported by CDC, comparing ten men new vaccine's effectiveness. Dr. Theodore Non Effects - Side - Side Effects When three elderly heart patients died on October 11, hours after receiving the flu vaccine in a Pittsburgh clinic, it produced headlines throughout the country and vaccinations dropped precipitously. Head- lines featured daily body counts. The total who died within a few days of receiving bivalent (swine and Victoria) vaccine reached 38 within the first week. Although later investigation showed the deaths to be coincidental, as government officials initially asserted, the credibility of the mass vaccination program had been seriously weakened by trying to pass off this initial educated guess as fact. When 2 million high - risk persons are vac- cinated in one week (only bivalent vaccine was being given at that time) a certain number can be expected to die suddenly of other causes. CDC analysis of the 38 reported cases showed that the number of deaths probably reflected the extent to which physicians connected deaths of their patients with vaccination. Over half of the deaths were autopsied, showing causes of death within the normal range for old people who die suddenly: a lot of heart attacks and one ruptured aneurysm. The absence of deaths in the first hour af- ter vaccination indicates that none was due to allergic reactions, which would oc- cur within minutes of vaccination. (1) One cardiologist hypothesized that the stress of waiting in line, getting the injection or any other stress might cause a person already on the verge of having a heart attack to do so a few hours earlier. Fever is a classic type of stress that produces such a response, but the deaths do not correlate with the time when fever effects side - of the vaccine should occur. The most important effect of the hysteria has been to decrease the number of people who will get vaccinated this year, a serious problem for high - risk people who really do need the vaccine especially - against A Victoria/ 7/5. See References pages 19, 20 Cooper, DHEW Assistant Secretary for Health, says that government experts " agree that, in recent years, flu vaccine has been up to 90 percent effective when the infecting virus matches the virus used in the vaccine. They anticipate similar performance from the swine flu vaccine. " (9) Similarly, CDC has estimated that " at least 70% of the individuals receiving the New A / Jersey influenza vaccine will be fully protected against that strain for the coming fall and winter influenza season. " (10) Governmental optimism was boosted by an extensive study sponsored by the Public Health Service and reported in a June 21 conference. 5,200 volunteers were injected with the flu flu vaccine, mostly A New / Jersey / 76 and / or A Victoria / / 75, in in the dosages being recommended. Antibody levels to the vaccine before and two weeks after the vaccination were measured. About 90 percent of the subjects over 25 showed a large antibody response, although only 28 to 58 percent (depending on which company's vaccine) of the subjects between 18 and 24 had adequate antibody responses. (11) Government reports and many scientists have equated antibody response with vaccine effectiveness, that is, the extent to which the vaccine will prevent a person from becoming ill after exposure to the naturally occurring flu virus. This equation, however, has been questioned by some scientists. Dr. J. Anthony Morris, a former section director of FDA's Bureau of Biologics, argues that " Flu vaccine made from inactivated particles, like the one now being manufactured, produces'the wrong kind of immunity.'It elicits systemic antibody [immune globulin G] that can be measured in the blood, but does not produce the local antibody [immune globulin A], in the lungs and nose, which is needed to protect against infection by the flu virus. " Morris estimated the effectiveness of the flu vaccine against A New / Jersey / 76 to be only about 20 percent. When the Government Accounting Office, a watchdog agency of the US 11 Congress, asked other scientists to assess the vaccine's effectiveness, the estimates ranged from 25 to 73 percent. (12) Public criticism from within the govern- ment infuriated Morris'superiors. In the early 1970s, Morris and his attorney, James S. Turner, had been key figures in instigating Congressional hearings on the management of federally coordinated vac- cination programs. (13) The result of the hearings was a transfer of responsibility for regulation of vaccine safety and efficacy to the FDA and the creation within FDA of the presence of symptoms (fevers and respira- tory symptoms) but an 80 percent efficacy rate when they defined influenza by blood antibody levels. (17) Another study done during the Hong Kong flu epidemic of 1968 concluded that: " The results indicated that the optimally constituted influenza vaccines at standard dosage levels have little, if any, effectiveness. " (18) In the last analysis, it is clear that there is simply not enough data to evaluate the efficacy of influenza vaccines, especially those developed during the past Bureau of Biologics. In July, 1976, Morris was fired from his position in the FDA. FDA Commissioner Alexander Schmidt claimed that he was fired for " inefficiency and insubordination, " and that the timing was " coincidental.'' (14) Morris'arguments about the efficacy of vaccines are controversial. He argues that in some cases flu vaccination may increase susceptibility to the flu; in his Congressional testimony he cites two unpublished 1968 studies in which vaccinated sailors and industrial workers had rates of flu that were more than twice that of their unvaccinated peers (54 to 55 percent vs. 25 to 26 percent). (15) Morris'arguments are buttressed by an NIH workshop on the long term - conse- quences of killed (formaldehyde- inactivated) viral vaccines. It described two such viral vaccines (against measles and respiratory syncytial virus) in which prior immunization with killed vaccine caused DRUG COMPANIES vaccine recipients to become more ill than vaccine non - recipients when exposed to the natural virus. (16) Government experts admit that their evi- dence about field efficacy is woefully inad- equate. There are many experiments in which subjects were vaccinated against an influenza strain and then given a " challenge dose " of that influenza virus; the efficacy under these circumstances is often over 70 Plympton percent. But there have been very few adequate studies of the protective value of vaccination against a real epidemic. One of the few good prospective studies on the fate wal ly. ears, which have not been field tested - SIDE EFFECTS actual efficacy of flu vaccines was done in In essence, flu vaccines induce a mild 1968-69 in Tokyo. Initial doses of vaccine version of the flu in order to prevent a much comparable to those being used this year were followed by a booster of the same dose. more serious illness later. Generally, the most serious symptoms of this milder illness Researchers found no statistically significant are low fever, headache, muscular aches and 12 correlation between vaccination and the generalized weakness. The June 21 PHS Conference reported that only about two percent of those over 24 years old had such symptoms, although it is reasonable to assume that a much larger number of people experienced milder symptoms. The Conference also reported an unac- ceptably high rate of side effects in children aged three to ten (they did no testing of children under three). A dose two - regimen process is imperfect, some egg proteins remain in the final product. For this reason public health officials have routinely alerted egg allergic - people not to be vaccinated. Although there have never been any reported deaths from allergic reactions to earlier influenza vaccines, the report of the June 21 PHS Conference lists five separate individuals whose reactions to the vaccine for children was more recently approved, but the matter is of no great concern, since children do not get particularly sick from flu. were considered to be allergic. (20) THE SABIN SWITCH The high level of side effects was a setback, however, for those scientists who had hoped to actually prevent an epidemic from occurring by by vaccinating vaccinating " every man, woman and child, " since children are major Perhaps the most telling blow was struck by Dr. Albert Sabin, who publicly abandoned the program in early November. Sabin, like so many others, went along with David Sencer's initial memo to President on the carriers of epidemics like the flu. Mean- while, young adults (18 to 24) had side effect rates intermediate between children and older adults. (19) The flu virus is routinely grown in fertilized eggs. Because the purification basis of available evidence at the time. He has sufficient stature, due to his pioneering work in developing the polio vaccine, that his opposition to Sencer's plan would have cast a shadow over the program at its inception. Sabin's support certainly cannot be at- tributed to dependency on federal research monies, since his prestige has guaranteed Informed Consent? funding from numerous sources. Sabin began to rethink his position as The reality of effects side - from vaccines, negative information on the mass vaccination program began to accumulate. His doubts some of which are quite severe, though seldom fatal, forces the government to deal, at least in a limited fashion, with the grew after the June 21 meeting, when the poor antibody response of those under 25 led him to seriously question vaccinating young issues of informed consent. When the final people. He also began to challenge the use of insurance law for the mass vaccine vaccine on non high - - risk people in general. program (PL 94-380) was passed, it contained a pro forma - requirement that the government vaccinators get approval from the National Commission for the Then, on November 5, he stated publicly that the possibility of a swine flu epidemic is " now practically negligible. "'(21) Protection of Human Subjects of Biomedi- cal and Behavioral Research (a DHEW ALTERNATIVES watchdog Commission on the civil rights of patients and research subjects) for their The speed with which the federal informed consent procedures. This proved no small matter: the vaccinators had government had to make a go or no go - decision on the mass vaccination program printed up 60 million consent forms labelled " Registration " forms. The Na- tional Commission seriously challenged the intentionally misleading character of the forms and suggested that they be discarded, but PHS officials have proceed- ed to use these forms anyway. By ignoring the Commission's challenge, they are skirting at least the spirit if not the letter of seemed to preclude the possibility of public discussion of alternative programs. As noted earlier, CDC identified New A / Jersey / 76 on February 13 and made the first public announcement of its discovery on February 19. Very soon thereafter the Bureau of Biologics set April 1 as the target date by which a decision had to be made. Five or six weeks hardly allowed time for the govern- the law. ment to crank up administrative machinery See References pages 19, 20 for a major public health decision, let alone a for public discussion. 13 a Swine Flu Insurers: Legion Heirs The mass vaccination program had scarcely been announced before the drug industry began voicing fears about obtaining insurance coverage for the production of vaccine. The fact that such coverage is necessary has a history in the 20 year - - old tension among government, drug companies and insurance companies over vaccine safety and liability for public protection in their use: * In 1955 a batch of polio vaccine made by Cutter Laboratories and contained inadequately inactivated polio virus caused ten deaths and 192 cases of paralytic polio. (1) * In 1961, Dr. Bernice Eddy, Division of Biologic Standards (predecessor of the FDA's Bureau of Biologics), showed that some of the polio vaccine being used was heavily contaminated with " SV - 40, " a virus that had been shown to produce cancer in several animals. (2) * Finally, last year, a federal court found (Reyes vs. Wyeth, 1975) a drug company liable when a child got polio from polio vaccine. Since no " doctor- patient " relationship existed, thus making " informed consent " impossible in the public clinic where the vaccine was administered, the company was held responsible for informing the child's parents that one possible complication of polio vaccination is the development of polio. This landmark decision had _ its greatest impact on the insurance companies, now faced with coverage of a large, potentially open ended - liability. Since 1975, these insurance companies have been threatening to get out of the vaccination insurance business, in what seems to be part of a long term - strategy to abandon the medical malpractice field altogether. Argonaut, for one, has openly stated its interest in getting out of the malpractice field; in late 1974-75, the whole industry began pressuring for huge increases in malpractice rates. Despite variable success, the industry as a whole was disappointed and continued to express its disillusionment with malpractice coverage. On April 12, the day the House of Representatives passed the $ 135 million funding bill for mass flu vaccination, Merck & Co. requested relief from claims arising from adverse reactions to the vaccine. Over the next few months drug companies repeatedly told DHEW, CDC and the press that their insurance carriers were not offering coverage for liability claims arising from swine flu vaccine production. The most frequent excuse was the fear that anyone who got as much as a cold after vaccination would file a " nuisance " suit, costing a lot of money to defend in court even if the company won. At no time did drug or insurance firms publicly state qualms about any dangerous side- Further limiting policy alternatives is the lack of an extensive, coordinated public health system in the US to quickly implement such a vaccination program. In European industrial countries, for instance, the start - up time would be shorter because neighborhood and workplace health delivery mechanisms are generally already in place. The only alternative extensively discussed since President Ford's announcement of the program has been production of the vaccine and stockpiling it until a possible reap- pearance of A New / Jersey / 76 - at which 14 time a mass vaccination program might be implemented. The stockpiling strategy is a questionable one, however, since the main delay in any future vaccination program would stem from the bureaucratic bottleneck of administration rather than from delays in vaccine production. The 1918 flu spread rapidly and erratically; even the less virulent Asian and Hong Kong flus spread worldwide within a few weeks. Since it takes about two weeks after vaccination for the vaccine to become fully effective, the disease could therefore spread throughout the population before a mass program could be imple- mented. effects of the vaccine. Historically, however, there have been few liability suits over flu vaccines and the cost of a losing court case is usually borne by the loser of the case. In fact, unless one bears in mind the insurance companies'desire to get out of malpractice coverage, the level of industry panic is difficult to under- stand. In a similar vein, physicians, hospitals and clinics were being told by the insurance companies that they would not be covered by normal mal- practice insurance if they participated in the mass campaign, yet there is no equivalent of the " Reyes case " for these private facilities and they have no responsibility beyond normal medical care liability. Most of July and August was con- sumed with multiple delays, with the struggle continuing between the insur- ance companies and the federal govern- ment about liability insurance. The carriers asked Congress for legislation exempting them from lawsuits result- ing from adverse reactions and limiting liability exclusively to claims that could prove negligence in vaccine production. The House Health and Environment Subcommittee, chaired by Paul G. Rogers, refused, with the backing of HEW, since " such a government indemnity could become a precedent of far reaching - consequence for other vaccines and drugs. DHEW officials would actually prefer a less drastic - solution: The government would prom- ise to inform patients of vaccine risks and obtain their consent before they took the shots. " (3) Meanwhile, the drug companies continued production but refused to sell it to the federal government until the liability issue was resolved. The resolu- tion came on August 3, when " amid initial reprots that swine flu was among the diseases being considered as the cause of the mysterious illness that invaded a meeting of American Le- gionnaires in Philadelphia, the Com- merce Committee's Health Subcom- mittee quickly reported a swine flu liability bill and sent it to the full Com- mittee. Under the bill, anyone who claims injury from the program would have to sue the federal government for damages. Should the court award damages for negligence, the federal government could in turn sue the negligent party to recover the awarded damages. A key provision of the bill states that hospitals, physicians, para- medical personnel and distributors would be given this federal liability coverage provided - they did not charge for administering the flu vaccine. " (4) Wisely seizing upon the panic created by the government's own speculation about the Legionnaires ' Disease, the drug and the insurance industry unlike the American public Lgot even more than they had originally requested. See References pages 19, 20 The real alternative, a high - risk - only program, would save the amount of money that was going into production of vaccine for non high - - risk people. The cost of the 40 million doses to vaccinate all high - risk Americans would be about $ 20 million, compared to the $ 100 million now being spent for 200 million doses. The $ 80 million saving could have been spent on finding and vaccinating high - risk people - in recent years, an average of only 10 million people (fourth one - ) of all high risk people have actually received flu vaccine. Or it could have been spent on any of a dozen other public health projects that are desperately needed and seriously underfunded. The real bene- factors of the $ 80 million now are the drug companies. RESISTANCE TO CHANGE If the decision to vaccinate all Americans were simply a medical decision, no doubt the mass program would have been abandoned long ago in favor of a reasonable alternative, such as vaccinating only high - risk people. Medical decisions never occur outside a social context, however, especially when they affect entire populations. 15 SWINE FLU Bill Plympton Once the Ford Administration, following recommendations of public health officials and prominent medical scientists, decided to proceed with the program, a whole series of interests were unleashed which stood to benefit from it. These, combined with the Administration's election year imperatives, were so powerful in stabilizing the program that it continues despite a preponderance of medical evidence against it. Among these interests are middle - level public health officials, drug companies and and private physicians, and large employers in general. * Public Health Officials: Emerging from the often routine and thankless world of public health administration, many officials are still wide - eyed at the sudden glare of publicity produced by the swine flu program. Dr. Harry Meyer, Director of the Bureau of Biologics, put it clearly: " In the world I deal with every day, there are so many things you do that are not terribly interesting, but which are called'real chores.'To have a challenge of something that is a real public health 16 interest is really stimulating. " (22) From a more mundane perspective, public health officials have a vested interest in pursuing a program which at least prevents them from looking bad. " It's a lot better to do something and be wrong than to do nothing and be faced with a terrible epidemic. " (23) As a result, support for the program among public health officials has remained strong. * Drug Companies: Drug companies were delighted at the prospect of a federal financial injection of $ 100 million for producing the vaccine. The amount seems to have been derived from a 50 cents - per - dose cost for the smaller lots manufactured in the past. Since economies of scale were inevitable for the mass program, they stood to profit enormously. The $ 100 million was to be divided among four drug companies (two of which have sordid histories, in the marketing of thalidomide and chloram- phenicol), apparently irrespective of how the program itself fared. The appropriation came long before anyone knew how many inactivated virus particles would be needed per dose (the first test results were not reported until three months later) or how many doses would actually be needed and hence produced. * Private Physicians: Private, fee for- - service physicians obviously derive benefit from the program from the large number of patients they will see in their practices. Some are volunteering in free public vaccination programs; most, however, will simply collect routine office fees. Although not permitted to charge patients for the cost of the vaccine, which comes free from the government, fees will be charged for other nominal services. * Large Employers: American business- men, especially those from large corpora- tions, generally favor the mass vaccination program. Their most obvious interest lies with non high - - risk Americans, for whom the program is the most questionable, since virtually all productive workers fall into that category. The program, from their vantage point, can be counted on to reduce absenteeism during the winter, thus en- hancing company productivity and profits. The Hong Kong pandemic of 1968-69 was estimated to have cost $ 3.9 billion in medical care, industrial absenteeism and future earnings of those who died. Corporate executives are all too happy to have the government (with a tax base that dispropor- tionately takes from the working classes) give them a $ 135 million insurance policy against potential damage to their earnings. * The Ford Administration: The key decision to go ahead with the mass program, and the later necessity to defend it against all criticism, came, of course, from the Ford Administration. Noted for having taken no initiative on any major health program (see BULLETIN, September / October, 1976), the swine flu program might take the edge off criticism that might arise during the campaign. At first blush, it was a no lose - program for President Ford: if there was an outbreak of swine flu, he had acted to protect the American people; if no outbreak material- ized, he could still say that he had protected them. The program became a win no - one, however, with few benefits, many rip offs -, growing cynicism and several deaths ap- parently caused by the vaccine a few weeks before the Presidential election. WHAT IS AN EPIDEMIC? If there are any lasting benefits from Ford's swine flu extravaganza, it may come from the questions it raises about the limitations of modern clinical medicine. The failures of the mass vaccination effort, along with the unsolved mystery of the Legion- naires'disease, bring unprecedented public attention to a growing controversy about those limitations. Based on a medical model that seeks a technical answer to every problem, modern clinical medicine largely ignores the social and emotional stresses so critical in producing major killer diseases such as heart disease, stroke (24) and cancer. (25) An unanswered question about influenza is the extent to which illness is caused by the virulence of the virus versus the health of the victim (usually spoken of as " host resis- tance "). Medicine recognizes the role of host resistance in susceptibility to many diseases, including infectious ones like herpes, but very little work has been done from this perspective on influenza. At the most obvious level, the flu is much like the common cold: some people who are exposed to the virus become ill and others do not and the extent of illness is not simply proportion- al to the number of germs that have entered the body. In the most extreme cases, malnourished and other debilitated persons will become far more ill from the same exposure than healthy persons. In 1918 the world was well into its fourth year of the worst war it had ever experienced. There is no way to know what would happen if the identical virus were to reappear today, but it is highly unlikely that it would wreak such destruction as it did then. In 1918, world nutrition levels were lower, housing conditions everywhere were worse, and the effects of war, stress and fatigue are incalculable. Incredibly, how- ever, scientists and public health officials have generally failed to consider the question of host resistance in the case of A New / Jersey / 76. CONCLUSION: MEDICAL OVERKILL If the US economy were reasonably healthy and there existed a real national commitment to meet the health care needs of all the people, the medical overkill associat- ed with the swine flu program and its millions of dollars in wasted resources would be no great tragedy. With government budgets tight and health care programs being cut back, however, especially pre- ventive and primary care programs, misal- location of resources on such a scale is tragic. In Fiscal 1975, the total federal outlay for prevention and control of health problems was about $ 1 billion, just three percent of the federal health budget. (26) Thus the $ 135 million associated with the swine flu program represents about thirteen percent of all federal expenditures for prevention and control. It rivals the $ 170 million spent annually for all occupational health activi- ties, and far exceeds the $ 30 million yearly budget of the National Institute for Occupa- tional Safety and Health, the chief agency for The Hong Kong pandemic of 1968-69 was estimated to have cost $ 3.9 billion in medical care, industrial absenteeism and future earnings of those who died. 17 Epidemic: Germs or Social Factors? There is a long history of conflict between those medical people who feel that diseases and epidemics are caused solely by germs and those who feel they are caused by economic, social and psycho- logical factors that make the host less resistant to germs around them. " In 1847 Virchow was sent by the Prussian government to investigate a typhus epidemic.... Virchow's recommenda- tions.. called. for full employment, better nutrition and sanitation, raise in wages, separation of church and state, restoration of native language, public education, self government - , shifting of tax burden from poor to rich, creation of agricultural cooperatives, etc. " (1) Virchow's suggestions represented the thinking of the anti contagionists - , who said that disease came from local conditions and opposed quarantines (hence obtaining support from commercial interests " who did not want ports tied up. ") They were opposed by the contagionists, " who took the position that disease comes from the outside, needs quarantine and related bureaucracy.... When the germ theory was developed, it would seem natural... that germs were also a necessary but not sufficient condition for disease production -but. germs became heralded as. the sole cause of disease production to the total exclusion of social factors. " (2) See References pages 19, 20 occupational health research in the US government. It is about twice the total spent on noise control and abatement (27) and dwarfs the few million dollars spent yearly by the government on its anti smoking - efforts. The swine flu program is a diversion in another way, as well. Touted by its supporters as a major preventive health program, it was in fact a narrowly defined preventive health program, within a tradi- tional medical model that seeks a technical fix for every health problem - a drug, a shot, a surgical procedure. For many years the preventive health field has put its major, almost exclusive, emphasis on infectious disease control, a strategy firmly situated within this medical model. Recently, under the impact of efforts to prevent heart disease, cancer and stroke, there has been increased emphasis on improved nutrition, physical conditioning, anti smoking - efforts, and control of environ- mental and occupational hazards. Some are even seeking a relation between the onset of disease and the physical and emotional stresses of late twentieth - century US capi- talism (e.g. see 28). The focus of the swine flu program emphasizes that which is most 18 traditional in preventive health, although renewed emphasis on traditional childhood vaccination programs is still needed in inner cities and rural areas. It also diverts attention and resources from those aspects of the field vitally important in the effort to bring under control such present epidemics as heart disease, cancer and stroke. The tragedy of the swine flu program, then, is not so much in what it does as in what urgent tasks it diverts us from. -Kenneth D. Rosenberg References 1. Walter Sullivan, " Experts in Europe Question U.S. Plan for Mass Flu Shots, " New York Times, June 9, 1976, page 1. 2. Cited in testimony of Sidney Wolfe and Anita Johnson of the (Washington, DC) Health Research Group before the House Health Subcommittee, June 28, 1976. 43.. 3.A .SuSl.li vBane,a irbei d.& J.W. Craig, " Virulence for Man of a Human Influenza - A Virus Antigenically Similar to ' Classical'Swine Viruses. " Lancet, July 3, 1976, page 4. 6. 5. Idem. 6. Michael hattwick, Richard O'Brien, Charles Hoke & Walter Dowdle, " Pandemic Influenza, The Swine Influ- enza Virus and the National Influenza Immunization Program,'" CDC National Influenza Immunization Program, Pamphlet Number 6. 7. Charles Stuart Harris -, " Swine Influenza in Man, " Lancet, July 3, 1976, page 32. 8. Editorial, " Planning for Epidemics, " Lancet, July 3, 1976, page 25. 9. Philip M. Boffey, " Swine Flu Vaccination Campaign: The Scientific Controversy Mounts, " Science, 193: 560, August 13, 1976. 10. " Influenza in the United States: Rationale for Mass Immunizations in 1976, " CDC National Influenza Immunization Program, Pamphlet Number 5. 11. Public Health Service, " Transcript of Proceedings: Meeting on Testing of Influenza Vaccines, " June 21, 1976, page 32a. 12. Robert Pear, " Scientist Says U.S. Fired Him For Criticizing Flu Shot Plan, " Washington Star, July 25, 1976, page A 19 -. 13. " Consumer Safety Act of 1972, " Hearings before the Subcommittee on Executive Reorganization and Gov- ernment Research before the Committee on Govern- ment Operations, US Senate, April 20-21 & May 3-4, 1972, pages 429-824. 14. Philip M. Boffey, " Federal Vaccine Agency: Critic Fired After Bitter Conflict, " Science, 193: 384, July 30, 1976. 15. Cited in " Consumer Safety Act of 1972 Hearings, " op cit., page 773. Dr. Morris says that the sailor study is cited in a letter from the ship's doctor, Dr. Weibenga, to John Seal, Director of Research of National institute of Allergy and Infectious Diseases and that the industrial worker study is cited in a letter from the tele- phone company to him. 16. John E. Craighead, " From the National Institutes of Health: Report of a Workshop: Disease Accentuation After Immunization with Inactivated Microbial Vac- cines, Journal of Infectious Diseases, 131: 749-754, June, 1975. 17. A. Sugiura, et. al., " A Field Trial for Evaluation of the Prophylactic Effect of Influenza Vaccine Containing Inactivated A2 Hong / Kong and B Influenza Viruses, " Journal of Infectious Diseases, 122: 472-478, December, 1970. 18. S.C. Schoenbaum, S.R. Mostow, W.R. Dowdle, M.T. Coleman & H.S. Kaye, " Studies with Inactivated Influenza Vaccines Purified by Zonal Centrifugation: Efficacy, " Bulletin of the World Health Organization, 41: 535 (1969). 19. Center for Disease Control, " Recommendation of the Public Health Service Advisory Committee on Immunization Practice: Influenza Vaccine, " Morbidity and Mortality Weekly Report, 25: 221, July 23, 1976. 20. Public Health Service, op. cit., pages 39, 43, 44 and 98. 21. Albert B. Sabin, " Washington and the Flu, " New York Times, November 5, 1976, Op Ed Page. 22. Philip M. Boffey, " Anatomy of a Decision: How the Nation Declared War on Swine Flu, " Science, 192: 636-641, May 14, 1976. 23. John Irvin, Director of Ohio's swine flu vaccination program, quoted in " Ready and Waiting: Flu Drives Are All Set to Roll - If the People And Vaccine Show Up, " Wall Street Journal, August 4, 1976, page 28. 24. Joe Eyer, " Hypertension as a Disease of Modern Society, " International Journal of Health Services, 5: 539-558 (1975). 25. John Cairns, " The Cancer Problem, " Scientific Ameri- can, November, 1975, pages 64-78. 26. " Special Analyses, Budget of the US Government, Fiscal Year 1975, US Government Pringing Office, Washington, DC, page 137. 27. Ibid., page 243. Additional references Howard Berliner & J. Warren Salmon, " Politics of Prevention: Swine Flu, the Phantom Threat, " The Nation, September 25, 1976, pages 269-272. Philip M. Boffey, " Swine Flu Vaccine: A Component is Missing, " Science, 193: 1224-1225, September 24, 1976. Philip M. Boffey, " Soft Evidence and Hard Sell, " New York Times Magazine, September 5, 1976, pages 8-31. Jane E. Brody, " Influenza Virus Continues to Keep Scientists Guessing, " New York Times, July 23, 1976, page A22. Bureau of Biologics, " Panel on Review of Viral Vaccines and Rickettsial Vaccines, " Seventeenth Meeting, June 22, 1976. Avail- able on cassette tape only; no transcript was prepared. Alexander Cockburn & James Ridgeway, Is " Death at the Door- step? Journal of the Plague Scare, " The Village Voice, October 25, 1976, pages 14-15. Consumer Reports, " Swine Flu: Did Uncle Sam Buy a Pig in a Poke? " September, 1976, pages 495-498. Alfred W. Crosby, Jr., Epidemic and Peace, 1918 (Westport, Connecticut: Greenwood Press, 1976). C.C. Dauer and R.E. Serfling, " Mortality from Influenza, " American Review of Respiratory Diseases, 83 (Part 2): 15-28 (1961). Douglas Gasner, " Swine Flu: The National Threat That Wasn't, " Medical Dimensions, September, 1976, pages 19-26. A.A. Hoehling, The Great Epidemic (Boston: Little, Brown & Company, 1961). Arthur Levin, " The Swine - Flu Plan: A Health Program in Search of a Disease, " New York, April 26, 1976, pages 57-64. Charles S. Marwick, " Swine Flu Immunization:'Go'At Last, " Medical World News, September 6, 1976, pages 60-72. Metropolitan Life Insurance Company, " Mortality from Influenza and Pneumonia, " Statistical Bulletin, September, 1976, pages 3-7. " Transcript of Proceedings: Meeting on Testing of Influenza Vaccines, " June 21, 1976, 201 pages. Donnel Nunes, " The Great Flu Epidemic of 1918, " Washington Post, May 23, 1976, pages C1 & C5. John Powles, " On the Limitations of Modern Medicine, " Science, Medicine and Man, 1 1-30: (1973). Judith Randal, " The Big Swine Flu Snafu, " New York Daily News, August 23, 24, 25, 1976. Boyce Rensberger, " U.S. Aide Doubts A Heavy Flu Toll, " New York Times, July 2, 1976, pages A1 & A8. Boyce Rensberger, " Flu Vaccine Drive Meets Snags That Could Limit It, " New York Times, July 23, 1976, pages A1 & A22. Richard M. Restak, " Flu Shots for 200 Million? " Washington Post, May 23, 1976, pages C1 & C4. Harold M. Schmeck, Jr., " First Flu Shots Given in Test of Vaccine for Mass Use Against Swine Virus, " New York Times, April 22, 1976. Harold M. Schmeck, Jr., " Flu Shots 4 Weeks Apart Found Safe for Those 3 to 18 Years Old, " New York Times, October 23, 1976, page 1. J.W.G. Smith, W.B. Fletcher, P.J. Wherry, " Future Prospects for the Control of Influenza by Immunoprophylaxis and Choice of Groups for Routine Vaccination, " Postgraduate Medical Journal, 52: 399-404, June, 1976; the entire issue is devoted to Influenza Vaccines. Jonathon Spivak, " Shot in the Arm?: Program to Inoculate All Americans for Flu Appears to be Ailing, " Wall Street Journal, June 18, 1976, pages 1 & 27. Michael Steinberg, " Swine Flu Vaccine: For the People or For the Profiteers? " MCHR News, Vol. 1, No. 1, September, 1976. Charles Stuart - Harris, " Pandemic Influenza: An Unresolved Problem in Prevention, " Journal of Infectious Diseases, 122: 108-115 (1970). Lawrence Wright, " Sweating Out the Swine Flu Scare, " New Times, June 11, 1976, pages 29-38. Barbara Yuncker, " Ford's Flu Shot Campaign: How Safe? How Necessary? " New York Post, April 24, 1976. Box References 1918 (page 3) 1. Louis Weinstein, M.D., " Influenza - 1918, A Revisit? " New 2. 2E.n Igdlema.n d Journal of Medicine 294 1059:, May 6, 1976. Was 1918 Swine Flu? (page 5) 1. Paul Brown, D. Carleton Gajdusek, J. Anthony Morris, " Virus of the 1918 Influenza Pandemic Era: New Evidence about its Antigenic Character, " Science 166: 117-119, October 3, 1969. 2. Ibid. Non Effects - Side - Side Effects (page 11) 1 Telephone interview with Dr. Craven, CDC National Influenza Immunization Program, October 27, 1976. 19 Swine Flu Insurers: Legion Heirs (page 14) 1 Nicholas Wade, " Division of Biologic Standards: In the Matter of J. Anthony Morris, " Science, February 25, 1972. 2 Nicholas Wade, " Division of Biologic Standards: Scientific Management Questioned, " Science, March 3, 1972; Samuel L. Katz, " Efficacy, Potential and Hazards of Vaccines, " New England Journal of Medicine, 270: 885-886 (1964). 3 Jonathon Spivak, " Program to Inoculate All Americans for Flu Appears to Be Ailing, " Wall Street Journal, June 18, 1976. 4 Washington Developments, Vol. 18, No. 31, August 9, 1976, p. 4. Epidemics: Germs or Social Factors? (page 18) 1. Howard Berliner, " Notes on Historical Precursors of Materialist Epidemiology, " Health Marxist Organization Packet # 1, April, 1976; available from Health / PAC. 2. Ibid. EE] HMO PACKET No. 2 Materialist Epidemiology Articles discussing the socio- economic aspects of the major causes of death including: hypertension coronary artery disease cancer drug addiction mental illness occupational diseases rheumatoid arthritis Available for $ 3 (Student) or $ 5 from: HMO c o / Health / PAC 17 Murray Street New York, New York 10007 2200 cause many doctors cannot or Vital Signs will not wait this length of time to be paid, the factoring ban will result in more doctors refusing to take Medicaid = THE MEDICAID BITE An sponsored HEW - Rand Corporation study in New York City suggests that medical care may be a major cause of families moving onto the welfare rolls. Short - term wel- patients. Thus by dealing with the symptom rather than the cause of the problem, Medi- caid reform penalizes the recipients. (Modern Healthcare, October 1976) fare families (on welfare for less than three years) use 50 percent more Medicaid ser- vices than do long term - wel- fare families, according to the study. The study shows Medi- caid to be the second largest welfare expense, accounting for one quarter - of all welfare expenditures. Each year, the typical welfare family (3.3 persons) receives an average of $ 1900 in direct welfare assistance, $ 1600 in Medicaid financed health care, $ 1500 in shelter allowances, $ 500 in food stamps, 460 $ in non- welfare earnings and $ 128 in social services. (American Medical News, October 4, 1976) NATIONAL HEALTH INSURANCE COSTS If recent months have failed to produce legislative activity on the national health insur- ance issue, they have produc- ed studies, some of them influential. One of these, a Rand Corporation study con- ducted by Bridger M. Mitchell and William B. Schwartz, was published in Science on May 14. It found the cost impact of four major bills (Ribicoff Long - , Kennedy - Labor, Nixon, and Kennedy - Mills) to be surpris- ingly similar in many respects. Costs to middle and upper income families, for instance, were similar for all four MEDICAID REFORM: PENALIZING THE PATIENT In response to the growing storm over Medicaid fraud, HEW has acted to ban factor- measures with the exception of the Kennedy - Labor bill, which costs substantially more for upper income families. Simi- larly, the cost to families with incomes under 15,000 $ was ing, a widespread practice in the Medicaid program. Fac- toring firms immediately ad- vance a physician money owed in Medicaid claims less a fee very similar for all four bills with the exception of the old Nixon - CHIP bill, which cost substantially more for low income families. Policy makers (often substantial). These claims are held until they are hope this study will form the basis for a new compromise paid by Medicaid and the firm measure. pockets the full amount. The More recently, a _ study practice has spread because of conducted by Gordon R. Trap- extensive delays by many nell, consulting actuary for states in paying Medicaid HEW, finds Kennedy - Labor claims delays - exceeding a not the most expensive bill. year in some instances. Be- Topping the list in expense is 21 the American Hospital As- sociation plan, spearheaded by Al Ullman, chairman of the House Ways and Means Com- mittee, at a cost of $ 200.4 billion. Following it in cost are Kennedy - Labor, $ 200.2 bil- lion; the American Medical Association bill, $ 196.6 billion; the old Nixon - CHIP plan, $ 189.3 billion; the health in- surance industry bill, $ 189.1 billion; and Long Ribicoff -, $ 188.1 billion. Even without passage of a national health insurance measure, health costs are expected to reach $ 180.2 billion by 1980, the year for which costs are projected. Trapnell found benefits of the Kennedy bill to be by far the broadest. (American MAepdriilc a1l7 ,N 1e9w7s6,; New York York Times October 18, 1976) ' ARBITRATION BINDS HOSPITAL WORKERS The bitter eleven - day strike of 40,000 nonprofessional health workers represented by District 1199, National Union of Hospital & Health Care Employees, against 57 New York City voluntary hospitals and nursing homes last July has resulted in an equally bitter settlement brought about by binding arbitration accepted to finally settle the strike. Retroactive to July, present wages were frozen for six months. Subsequently workers will receive a 4% percent wage increase which will not become part of base pay, now a minimum of $ 9,412 a year. The union had asked for a 9.95 $ a week wage increase, a one year - contract, larger pensions and vacations, in- 22 creased sick leave and other fringe benefits. The settle- ment, far below that recom- mended in the preceding months by a federal mediation commission, was characteriz- ed by Mel Foner, 1199 execu- tive secretary, as " a bitter disappointment to our mem- bers and a major setback for future labor peace in the voluntary hospitals. ' (New York Times, September 16, 1976) HILL BURTON - AND FREE CARE Hospitals required to pro- vide free care under the Burton Hill - program must now post multilingual signs signs or distribute written notices stat- ing whether the hospitals'free care obligations have been met and, if not, when free care is available. This results from new HEW regulations which also require that decisions concerning free care be made before a patient is treated. In the past hospitals were allow- ed to write off bad debts to meet free care obligations. Hospitals which have received Hill Burton - construction grants must provide 10 percent of the grant monies in free care; those receiving Hill Bur- - ton loans must provide three percent of operating costs over a 20 year period in free care. (Medical World News, October 17, 1975) SCIENCE BY THE PEOPLE Last year high levels of asbestos were found in the air throughout the Washington, D.C., metropolitan area; resi- dents have been understand- ably upset ever since. At the time, Dr. Irving Selikoff of Mt. Sinai Medical Center, a na- tionally known expert on asbestos hazards, suggested that the high levels might be caused by wear - and - tear on auto brake linings and clutch plates from local cars. Two amateur rockhounds, Don Maxey and Raymond Kent, school teachers in sub- urban Maryland, were skepti- cal. They thought that the cause was natural asbestos in the serpentine rock used widely on D.C. roads and driveways and mined at a large quarry in Rockville, Md. As cars rode over the rock, they believed, it disintegrated and released asbestos fibers into the air. To check their theory, they took samples from the quarry and, under the largest magnification of a student's microscope, saw asbestos fi- bers. The two contacted Dr. Arthur Rohl, an associate of Selikoff at Mt. Sinai, who confirmed their findings. In August the four announced their finding to D.C. officials for local action. (The Washington Post, August 11, 1976) ... SPEAK NO EVIL A Committee of the Phila- delphia County Medical Socie- ty conducted an eight - year study of hospital deaths be- lieved to be caused by mal- practice, reports the New York Times (October 4 4,, 1976). Fearful of lawsuits, the Com- mittee never kept records, disciplined doctors or notified the State Board of Medical Education and Licensure of its findings. At most doctors were sent " instructional " letters. " A lot of people were.. very, very fearful that there was an element of malpractice here that we had to be careful of, " commented the Commit- tee head. The Committee was disbanded two years ago. fiscal year 1977 was enacted into law September 30 when Congress overrode a Ford veto. The bill exceeded the OLD COSTS, NEW FORMS Ford Administration request by about $ 4 billion. Attached to counter criticism of the bill was an amendment hospital cost increases, the American Hospital Associa- tion has just devised its own indices which separate cost increases due to increased banning Medicaid payment for abortions except when the life of the mother is endangered. Women's and civil rights groups immediately went to services from those due to court and won a temporary price inflation. Using these, the AHA finds, " The reason hospital expenditures are seemingly rising faster than others is due directly to improvement in the product- hospitals care. " The Hospital Intensity In- dex, measuring the frequency and complexity of hospital restraining order, and a final decision regarding the legality of the amendment promises to take years in the federal courts. (Washington Report on Medicine and Health, October 4, 1976; Health Law Newsletter, October 1976) services, indicates that inten- sity of hospital services has increased at an annual rate of 4.8 percent in the last six years. This accounts for 28.5 percent of hospital cost in- creases between 1972 and 1974. The Health Manpower Act, three years in formulation, was finally passed and signed into law on October 13. This $ 2.1 billion measure continues fed- The Hospital Input Price Index, measuring increases due to inflation in the labor and products the hospital must purchase, accounted for 71.5 percent of cost increases in the same period. Cost increases eral funding to medical, osteo- pathic and dental schools while trying to deal with geographic and specialty maldistribution of doctors. The program will pay $ 2100 per year for each medical student (down from are standardly measured by $ 2500), but makes several the Hospital Service Charge demands on medical schools. component of the Consumer The measure requires 35 Price Index, which measure percent of all residencies be in increases in what patients pay. primary care specialties by Excluding increased intensity, 1978, 40 percent by 1979 and hospital cost increases paral - 50 percent by 1980. It also leled others in the CPI, states requires schools to accept the AHA. Americans forced to attend (American Hospital Associa- medical schools abroad in their tion Press Release, September 21, 1976) third year and puts new restrictions on foreign medical LEGISLATION OF NOTE: graduates seeking entry to the US. The bill increases funding of the National Health Service The $ 56.6 billion Labor- Corps (NHSC) _ scholarship HEW Appropriations bill for program from $ 22 million now to a maximum of $ 200 million by 1980. NHSC sends young doctors to medically under- served areas in return for cancellation of educational debts. The measure takes effect next October. (New York Times, October 14, 1976; Medical World News, October 4, 1976) After four years of contro- versy, a compromise version of the Toxic Substances Control Act was passed and signed by President Ford on October 12. As originally conceived, the bill required testing all chemi- cal products for health hazards before marketing. Dropping this provision, the Act as finally passed simply requires that companies notify the Environmental Protection Agency (EPA) of all new products at least 90 days before they are introduced commercially. If EPA decides the materials are potentially dangerous, they can require testing. Thus the responsibili- ty to assure testing falls not on industry but on on the gov- ernment, whose Environ- mental Protection Agency is already overworked and under heavy industry attack. An industry displeased with EPA's order to test a chemical can appeal the order in the federal courts and stay the decision until the court acts, which may take years. The final bill is very similar to the version originally passed by the House, which the chemical industry was reported earlier to have considered " the best deal possible. " ' (New York Times, September 7 and October 13, 1976) 23 Cumulative Index December ( 31, 1976) A Abbott Laboratories - Sept. - Oct. '76 * Abortion - Dec. '69; Mar. '70; Nov. '70; Dec. '70; Feb. '73; Nov. - Dec. '76. Affiliations June '68; Aug. '68; Nov. - Dec. '68; Winter '69; Jul Aug. -. '69; Apr. '69; Dec. '71; Sept. '73 (Montefiore - Prisons); Oct. '73 (Bellevue NYU -) ; Jan. - Feb. '74 (Montefiore - North Central Bronx). Air Pollution - Oct. '70; Nov. - Dec. '74. Alford, Robert R. June - May - '76 (Review). American Association for Labor Legislation - Jul. - Aug. '76 * American Assn. of Foundations for Medical Care - Feb. '73; July - Aug. '74. American Assn. of Inhalation Therapists - Nov. '72. American College of Obstetricians and Gynecologists - Jan. - Feb. '75; July Aug -. '75. American Conf. of Gov't. and Industrial Hygienists - Sept. '72. American Hospital Assn. - Nov. '72; July - Aug. '74; June May - '75; May June - '76. American Medical Assn. - Nov. '72; July - Aug. 174; Jan. - Feb. '75; May June - '75; July - Aug. '75; Jan. - Feb. '76 *; Mar. - Apr. '76; May June - '76 *; Sept. - Oct. '76 *. American Natl. Standards Institute - Sept. '72. American Nurses Assn. - Nov. '72; Sept. - Oct. '75. Asbestos - Mar. '73; Nov. - Dec. '74; July - Aug. '76 (letter). Assn. for Retarded Children - Jan. '73. Assn. for Voluntary Sterilization - Jan. - Feb. '75; July - Aug. '75. Association of American Medical Colleges - July - Aug. '69. Attica Prison - Nov. '71; Sept. '73 (Prison Health). B Beasley, Dr. Joseph - Sept. - Oct. '75. Bellevue Hospital - Sept. '73 (Prison Ward); Oct. '73. Beryllium Poisoning - Sept. '72. Beth Israel Hospital - July '68; July - Aug. '69; Sept. '69; Apr. '70; Oct. '70; Jul Aug. -. '72. Beverly Enterprises - Apr. '73. Birth Control - Apr. '72; Jan. - Feb. '75; July - Aug. '75. Black Lung Disease - Sept. '71. Blue Cross - Jul. - Aug. '69; Sept. '69; Oct. '69; Mar. '71; Jul Aug. -. '72; Oct. '72; Sept. - Oct. '74; May June - '75; May June - '76 *. Boston City Hospital - Jul. - Aug. '70; Oct. '73; Mar. - Apr. '74 - (letter); May June - '74 (letter). Boston University Medical Center - Oct. '73. Brian, Earl - Apr. 173. Brindle, James - Oct. '72. Buffalo Medical School - Nov. '71. Bureau of Occupational Safety and Health - Sept. '72. Byssinosis - Sept. '72. C California Public Hospitals - Apr. '73; May June - '74. California Nursing Assn. - Sept. - Oct. 174. Carnegie Foundation - Nov. '71; May June - '75. Carter, Jimmy (Sept. Pres.) - - Oct. '76. Case Western Reserve Med. School - Jan. '70; Sept. '71. Center for the Prevention of Violence - Sept. '73. Certified Hospital Admission Program - Feb. '73. Charity Hospital (New Orleans) -Sept. - Oct. '75. Cherkasky Cherkasky, Dr. Martin - Apr. '69; Jan. - Feb. '74. Chicago Health Movement - Apr. '71. Children's Hospital Boston, -Mar. '72. Chinese Health System - Dec. '72. Chlorinated Hydrocarbons - May - June '76 *. CIBA Gelgy - Pharmaceutical Nov. Co. - - Dec. '75. Cincinnati People's Health Movement - Sept. '71. City University of NY Proposal (Med. School) -Oct. '72. Citywide Save Homes - Our - Committee (-May NY) '72. 24 Cleveland - Sept. '71. Coler Hospital - Oct. '69. Columbia Medical Center - Jul. '68; Aug. '68; Nov. - Dec. '68; July Aug. -. '69; Sept. '69; Dec. '69; Feb. '70; Oct. '70; Dec. '70; Mar. '71. Columbia Hospital - Nov. '71. Columbus Hospital (-Nov NY) . '71; May '72; Oct. '72. Committee of Interns and Residents - Aug. '68; Sept. '69. Community Control - Oct. '68; Nov. - Dec. '69; Jan. '72; June '72. Community Medical School Proposal (Lincoln) -Oct. '72. Community Mental Health - Aug. '68; Apr. '69; May '69. (Lincoln); Dec. '69; May '73; July - Aug. '75. Comprehensive Health Insurance Plan (-Mar CH. I- PA)pr . '74. Coney Island Hospital - May '72. Cook County Hospital - Apr. '73. Cornell / New York Hospital - Sept. '69. D Davis Medical School (Univ. of Calif.) - Apr. '73; May June - '75. Delafield Hospital - Nov. - Dec. '68; May '72. Y' Diethylstilbestrol (-Ma-y JuDnEeS ')7 6 *. Depression, The Mar. - - Apr. '76. Downstate Medical Center - Sept. '69; Oct. '70. * Drug Companies - Sept. - Oct. '76. Dubos, Rene - Nov. - Dec. '75. Duke Medical School - July - Aug. '74. E Einstein Montefio-r eAp r-. '69; Sept. '69; Sept. '70; Oct. '70; Jan. '71; Nov. '71; May '73 (Einstein); Sept. '73 (Montefiore - Prisons); Jan. - Feb. '74. Eisenberg, Dr. Leon - Nov. - Dec. '75. Ellwood, Dr. Paul - Jul. - Aug. '72. Exchange Visitor Program - Jan. - Feb. '76. F Family Health Foundation - Sept. - Oct. '75. Federal Health Policy - Nov. '70; Apr. '71; May '73; May June - '78. Federation of Jewish Philanthropies - Apr. '69. Feldstein, Martin - May '73; Jan. - Feb. '74. Fiscal crisis - Mar. - Apr. '76. ERRATA The three tables published in the September / October 1976 Bulletin (Number 72) are incorrectly labelled. The cor- rect titles are: " Table 1 US Health Expenditures 1962-75 (in 000,000's), " " Table 2 Profit Making - Components of US Health Expenditures 1962-75 (in 000,000's). " The previous title showed the amounts " in 000s. " ' Food and Drug Admin. - Jan. - Feb. '75; Nov. - Dec. '75; Mar. - Apr. '76 *. Ford, Gerald (Sept. Pres.) - - Oct. '76. Fordham Hospital - Nov. - Dec. '68; Jul Aug. -. '69. Foreign Medical Graduates - Jan. - Feb. '76. Foucault, Michel - Nov. - Dec. '75. Free Clinics - Apr. '71; Oct. '71; Feb. '72; Mar. - Apr. '75. Freud, Sigmund - Jan. - Feb. '75. G Ghetto Medicine Jan Bill -. '70; Apr. '70; Jul Aug. -. '72. Group Health Insurance (-Oct NY). '72. Group Practice - Nov. '70; June '71. Gouverneur Hospital - Jul. '68; July. - Aug. '69; Nov. '69; Feb. '70. H Haight Ashbury - Free Clinic - Oct. '71; Feb. '72. Harlem Hospital - Jul. '68; Nov. - Dec. '68; June '69; Dec. '70. Harlem Medical School Proposal - Oct. '72. Harrington, Donald - Feb. '73. Harvard Medical School - Jan. '71; Oct. '73. HEW - Mar. '71; May '73; July - Aug. '74; Jan. - Feb. '75; July - Aug. '75; Nov. - Dec. '75; Mar. - Apr. '76 *. Health and Hospitals Corporation - Winter '69; June '69, Sept. '69; Nov. '69; Jan. '71; Dec. '71; Feb. '72; May '72; Oct. '73; Jan. - Feb. '74; July - Aug. '75; Mar. - Apr. '76; Nov. - Dec. '76 *. Health and Hospitals Planning Council - June '68; Winter '69; Jul Aug. -. '69; Sept. '69; Apr. '71; May '72; May '73; Mar. - Apr. '76. Health Care Costs - Jan. '70; Nov. '70; June '71; May '72; Jul Aug. -. '72; Jan. - Feb. '75; May June - '75; Sept. - Oct. '75; Mar. - Apr. '76 *; May June - '76 "; Nov. - Dec. '76 *. Health Inc., Boston - Mar. '72. Health Insurance Plan of Greater NY Oct -. '72; Dec. '72. Health Maintenance Organizations HMO) '-sN ov(. '70; Apr. '71; Dec. '71; Jul Aug.. '72; Oct. '72 (HIP); Feb. '73 (Foundations); Nov. '73 (Kaiser); May June - '75. Health Planning (see Health and Hosp. Planning Council) -June '68; Winter '69; Jul Aug. -. '69; Apr. '71; May '72; May June - '75; Jan. - Feb. '76; May June - '76. Health Professions Educational Assistance - Nov. '71; May '73. Health Revolutionary Unity Movement (HRUM) -Feb. '70; Jul Aug. -. '70; Sept. '70; Oct. '70; Dec. '70; June '71; Jan. '72; Jul Aug. -. '72. Health Services Administration - Jul. '68; Sept. '68; Sept. '69; Nov. Health Services Administration - Jul. '68; Sept. '68; Sept. '69; Nov. '69; Jan. '70; May '72; Sept. '73 (Prisons). Health Systems Agency (-May H-S JAu)ne '76; July - Aug. '76 ". Health Workers - Mar. '70; July Aug -. '70; Apr. '72; Nov. '72; Sept. - Oct. '74; Jan. - Feb. '75; Sept. - Oct. '75. Hill Burt-o nM a-y '72; Jul Aug. -. '72; May '73; May June - '75; Nov. - Dec. '76 *. Hilton Davis Co. (-Sept Strike) . '71. Holloman, Dr. John. L.S. (Mar. Jr.) - - Apr. '76. Home Health Services - Jan. - Feb. '76 *; May June -, '76 *. Hospital Expansion - Nov. '71; Mar. '72; May '72; Mar. - Apr. '74; Nov. - Dec. '74; May June - '75; Jan. - Feb. '76. Hospital Worker Unions - Jul. - Aug. '70; Sept. '70; June '71; Sept. '71; Oct. '72; Nov. '72; Jan. - Feb. '74; Sept. - Oct. '74; Nov. - Dec. '76 *. Human Experimentation - Jan. - Feb. '76 *; Mar. - Apr. '76 *. I Illich, Ivan July - - Aug. '75 (Review). Industrial Health Foundation - Sept. '72; Mar. '73; Nov. - Dec. '74. Industrial Medical Association - Sept. '72. Infant Formula - May - June '76 *. Institutional Licensure - Nov. '72. Insurance Companies - Nov. '69; Jul Aug. -. '72. Irvington House - Mar. '71. | Wor Kuen - Oct. '70. J Jacoby, Russell - Mar. - Apr. '75. Johns Manville - Corp. - Mar. '73; Nov. - Dec. '74. Joint Commission on Accreditation of Hospitals (JCAH) -Feb. '72; Apr. '73; July - Aug. '75; Jan. - Feb. '76 *; Sept. - Oct. '76 *. Judson Mobile Unit - Nov. '69. K Kaiser Permanen-t eNo v-. '70; Nov. '73; Mar. - Apr. '74 (letter). Key, Dr. Marcus - Sept. '72. King General Hospital - Apr. '73. Knickerbocker Hospital - Nov. - Dec. '68; Oct. '72. L Laing, R. D. Jan. - - Feb. '75. Law, Sylvia - Sept. - Oct. '74 (Review). Lead Poisoning - Sept. '68; Apr. '70; Jan. '71. Licensure Nov. '72. Life Expectancy - Sept. - Oct. '76 . Lincoln Hospital - Apr. '69; Sept. '70; Oct. '70; Dec. '70; Jan. '71; Jan. '72; July - Aug. '72; Nov. - Dec. '76. Lincoln Community Mental Health Center - May '69; Sept. '69. Logan, Dr. Arthur - Oct. '72. Louisiana State Univ. Medical Center - Sept. - Oct. '75. Lower East Side Neighborhood Health Council - South LESNHCS ) (- Jul.O ct'.6 '87;0. Jul Aug. -. '69; Sept. '69; Feb. '70; Apr. '70; Jul Aug. -. '70; M Madera County Hospital - Apr. '73. Maimonides Community Mental Health Center - May '68. Malpractice - May - June '75; Jan. - Feb. '76; May June - '76 *; Nov.- Dec. '76 *. Martin Luther King Health Center - Oct. '69. Maryland - Jan. - Feb. '76 (suburbs). Maternal and Child Care - May '73. Medicaid - Winter '69; June '69; Sept. '69; Jul Aug. -. '72; Oct. '72; Feb. '73 (Medi - Cal); Apr. '73 (Medi - Cal); May '73; May June - '74; Jan. - Feb. '76 "; Mar. - Apr. '76 *; Sept. - Oct. '76 *; Nov. - Dec. '76 *. Medicaid Mills - Jul. - Aug. '72; May June - '74. Medical Committee for Human Rights - Mar. - Apr. '75. Medical Education - Nov. '71; Oct. '72; May June - '75; Mar. - Apr. '76 *; Nov. - Dec. '76 *. Medical Empires - Nov. - Dec. '68; Apr. '69; Sept. '69; Oct. '70; Apr. '73 (Calif.); Jan. - Feb. '74; Mar. - Apr. '74; July - Aug. '74; Sept. - Oct. '75. Medical Industrial Complex - Nov. '69; Sept. - Oct. '76. Medical Labs - Mar. - Apr. '76 *. Medical Research - Nov. - Dec. '74; Nov. - Dec. '75. Medicare - June '69; Nov. '69; Jul Aug. -. '72; May '73; May June - '75; July - Aug. '75; Jan. - Feb. '76 "; Mar. - Apr. '76 *. Mental Health - May '69; Dec. '69; May '70; June '70; July - Aug. '75; Nov. - Dec. '75. Mental Retardation - Jan. '73. Merced County Hospital - Apr. '73. Methadone June '70. Methodist Hospital - Apr. '72. Metropolitan Hospital - Feb. '70. Michelson, William - Oct. '72. Military Medicine - Apr. '70; June '71. Mitchell, Juliet - Jan. - Feb. '75 (Review). Montefiore Hospital - June '68; Apr. '69; Sept. '69; Oct. '70; May '73; Jan. - Feb. '74. Moore, Dr. Cyril - Oct. '72. Morrisania Hospital - Apr. '69; May '72; Jan. - Feb. '74. Mothershead, Andrew O. Jan. - - Feb. '76 *. Mt. Sinai Medical Center - Oct. '70; Sept. - Oct. '74. 25 25 N Narcotics June '70; Dec. '70; Jan. '72. National Civic Federation - July - Aug. '76. *. National Health Corps - Apr. '70. National Health Insurance - June '69; Jan. '70; May '73; Mar - Apr. '74; May June - '74; Jul Aug. -. '74 (letter); Nov. - Dec. '76 *. National Health Insurance Program (-May NH- IJPun)e '74. National Health Planning and Resources Development Act (PL 93-641; 1974 -M-a yJu)ne '76; July - Aug. '76. National Institute for Occupational Safety and Health - Sept. '72; Mar. '73; Nov. - Dec. '74; Jan. - Feb. '75; July - Aug. '76. National Institutes of Health (-May NIH) '73. National Medical Enterprises - Apr. '73. National Safety Council - Sept. '72. Neighborhood Health Center - June '72; May '73. NENA (Northeast Neighborhood Assn.) - Jul. '68; Aug. '68; Oct. '70; June '72. New Orleans - Sept. - Oct. '75. New York City Municipal (public) Hospitals - Mar. - Apr. '76. New York City Prisons - Sept. '73. New York Infirmary - June '72. New York Medical College - May '69 (Community Mental Health Ctr.); Sept. '69; Oct. '70. New York State Dept. of Mental Hygiene - July - Aug. '75. New York Times - Feb. '70; May '70. New York University Medical Center - Sept. '69; Apr. '70 (Bennett); Oct. '70; Mar. '71; June '72; Sept. '73 (Prison Ward); Oct. '73. Nixon, Richard - Nov. '70; Apr. '71; May '73; Mar. - Apr. '74; Nov. - Dec. 74. North Central Bronx Hospital - May '72; Jan. - Feb. '74; Nov. - Dec. '76 *. Nursing - Mar. '70; Sept. '71; Apr. '72; Sept. '72 (letter); Nov. '72; Sept. - Oct. '74; Jan. - Feb. '75; Sept. - Oct. '75. Nursing Homes - Nov. '69; July - Aug. '76 *; Nov. - Dec. '76 *. Occupational Health - Feb. '70 (GE); May '71; Sept. '71; Sept. '72; Mar. '73; Nov. - Dec. '74; Jan. - Feb. '75; Sept. - Oct. '75; Mar. - Apr. '76 "; July - Aug. '76; Nov. - Dec. '76 *. Occupational Safety and Health Act Sept -. '72; July - Aug. '76. Occupational Safety and Health Administration - Sept. '72; Nov. - Dec. '74. Office of Management and Budget (-May OMB) '73. Oil, Chemical and Atomic Workers Union - Oct. '72; Nov. - Dec. '74; July - Aug. '76. Oil Industry - Nov. - Dec. '74. Oklahoma City Mar. - - Apr. 74. P Patient Dumping - May - June '74. Peace Movement - May '71. Pediatric Collective - Oct. '70; Jan. '71; Jan. '72. Peer Review - Feb. '73. Perot, H. Ross - July - Aug. '75. Physician's Assistants - Nov. '72. Physicians National Housestaff Association -May (PN- HJAu)ne '76 *. Piel Commission Report - June '68; Winter '69. Planned Parenthood - Jan. - Feb. '75; July - Aug. '75. Polyvinyl Chloride (-July P- VACug). '76. Prepaid Health Plans (PHP's) -Feb. '73; Apr. '73. Prisons - May '70; Nov. '71; Sept. '73. Professional Standards Review Organizations (PSRO's) -Feb. '73; July Aug -. '74. Profits in Health - Sept. - Oct. '76. Psychiatry - May '69; May '70; Jan. - Feb. '75; July - Aug. '75; Nov. - Dec. '75. Public Health Hospitals - Mar. '71. 26 Public Hospitals - April '73; May June - '74; Mar. - Apr. '76. Queens Medical School Proposal - Oct. '72. Quality Assurance Program (-July QAP) Aug -. '74. R Regional Medical Program - July - Aug. '69; May '73. Reich, Wilhelm - Jan. - Feb. '75. Research Guide - Feb. '71. Ritalin - Nov. - Dec. '75. Rockefeller, Nelson - July - Aug. '75. Rohatyn, Felix - Mar. - Apr. '76. S Sacramento County Hospital - Apr. '73. Sacramento Foundation for Medical Care - Feb. '73. Sacramento Medical Center - Apr. '73. San Francisco Hospitals - July - Aug. '70; Mar. '71; Feb. '72; Apr. '73; Sept. '73 (Prison Ward). San Joaquin Foundation for Medical Care - Feb. '73. Santa Cruz General Hospital - Jan. - Feb. '74. Selikoff, Dr. Irving - Sept. '72; Mar. '73; Nov. - Dec. '74. Shell Chemical Co. (No Pest Strip) -Sept. '71; Nov. - Dec. '74 (Strike). Smith, David - Oct. '71; Feb. '72. Social Workers - Sept. '70. Soundview - Throgs Neck Tremont - Comm. Mental Health Center- May '69. Stahl, Dr. William - Oct. '72. Sterilization Jan. - Feb. '75; Mar. - Apr. '75 (letter); July - Aug. '75; Jan. - Feb. '76 *. Sterling Drug Co. Sept -. '71. Student AMA - Mar. '70; Sept. '70. Student Health Organization (-Aug SHO) . '68; Mar. '70; Sept. '70; Mar. - Apr. '75. St. Joseph's Mercy Hospital (Ann Arbor) -Oct. '72. St. Vincent's Hospital - Jan. '70; Mar. '71; Jul Aug. -. '72. Swine Flu Nov. - Dec. '76. Sydenham Hospital - Nov. - Dec. '68. T Taylor, Frederick - Sept. - Oct. '75. Technicon Corp. - July - Aug. '74. Therapeutic Communities - June '70; July - Aug. '75. Think Linco-l Sne pt-. '70; Oct. '70; Jan. '71. Thursday Noon Committee - Feb. '72; Apr. '73. Tulane Medical Center - Sept. - Oct. '75. Tunnel Workers - Oct. '70. Trussel, Dr. Ray Nov. - - Dec. '68; Apr. '70; Jul Aug -. '72; Jan.- Feb. '74. U UCLA Medical Center - Jul. - Aug. '70; Sept. '73. United Harlem Drug Fighters - Oct. '70; Dec. '70. V Valley Medical Center - Apr. '73. Vanderbilt Clinic - May '70. Veterans Administration Hospitals - Apr. '70; May '71. Virchow, Dr. Rudolph - Nov. - Dec. '75. W Walsh - Healy Act Sept -. '72. Washington Heights - Inwood Community Mental Health Center- Nov. - Dec. '68; Apr. '69; Dec. '69. Washington, D.C. - Jan. - Feb. '76 (suburbs). Weinberger, Caspar - May '73. Welby, Marcus - May - June '74 (Review). Wender, Dr. Paul Nov. - - Dec. '75. Wesley Hospital (Chicago) -Jul. - Aug. '70. Willowbrook State School Jan.'73 -. L Women's Health - Mar. '70; Apr. 172; Dec. '72; Jan. - Feb. '75; July - Aug. '75. Workers'Compensation - July - Aug. '76. Y Yolo General Hospital - Apr. '73. Young Lords - Oct. '69; Feb. '70; Sept. '70; Oct. '70; Dec. '70; Jan. '72. BACK ISSUES HEALTH BULLETIN / PAC 1-9 copies, $ 1.25 each; 10 or more copies, $ 1.00 each. For orders of $ 10 or less, add 20% for postage; for orders over $ 10, add 10%. 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