1 Swine Flu: 7 Notes from NYC's Fiscal Crisis: 21 Vital Signs 24
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HEALTH PAC No. 73 November/December 1976 Health Policy WMM 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. 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 PLAY IT m . ,, . ,, _-___. A he swine flu vaccine program is the most ' recent chapter in the larger story of the UNCLE SAN fajiure 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. At the center of the action are the nation's effectiveness of the program have been medical scientists and their role in the voiced by the very scientists who initially development and implementation of govern- championed it. ment policy. Based on real fears of a The current federal strategy for protecting world-wide "killer" flu outbreak, these Americans against the swine flu is: (a) scientists, with their activist medical orien- vaccination of "high-risk" people with a tation, prematurely recommended a massive bivalent (two-virus) vaccine that seeks to program whose implications they barely protect them against both swine flu and comprehended. In so doing they took an ordinary Victoria flu viruses and (b) vaccina- active role in the decision-making process, tion of all other Americans eighteen years despite assertions by many of them that they and older against swine flu virus alone. are "just scientists" and technical advisors, On the basis of the available evidence outside the political process. Their presenta- there is no reason to dispute the vaccination tion of the facts and their inability or of high-risk people. High-risk persons are unwillingness to explore the ambiguities and those who would have a significant chance of uncertainties in their knowledge led the dying if they contracted influenza. They fall Executive branch to rush into a program that into two categories: those over 65 years of is ill-considered, mistargeted and largely age and those with serious, chronic diseases, ineffective. including: pulmonary disorders, such as Marching in close step behind these emphysema and severe asthma; heart scientists came the various private, interests disorders, especially mitral stenosis; meta- —especially large drug companies—who had bolic disorders, like diabetes and cystic flayed a smaller role in initiating the fibrosis; certain kidney disorders; and program but stood to gain substantially from deficiencies of the immune systems. Forty its implementation. Once these interests had million Americans, one-fifth of the popula- thrown their full corporate weight behind a tion, fall into these two categories and mass innoculation program, it became account for well over 80 percent of all deaths virtually impossible to reconsider it. This associated with recent influenza epidemics. latter point is all the more poignant since While the Federal government's strategy many of the growing doubts about the of vaccinating high-risk persons may be STATEMENT REQUIRED BY THE ACT OF AUGUST 12, 1970; 8. Known bondholders, mortgagees, and other security holders SECTION 3685, TITLE 39, UNITED STATES CODE, SHOWING owning or holding 1 percent or more of total amount of bonds, THE OWNERSHIP, MANAGEMENT AND CIRCULATION OF mortgages or other securities: None. THE HEALTH/PAC BULLETIN. 9. For completion by nonprofit organizations authorized to mail 1. Title of Publication: Health/PAC BULLETIN. at special rates (Section 132, 122, PSM) The purpose, function, and 2. Date of Filing: September 30,1976. nonprofit status of this organization and the exempt status for 3. Frequency of issue: Bi-monthly. Federal income tax purposes: Have not changed during preceding 3A. No. of issues published annually: Six. 12 months. '3B. Annual subscription price: student $8.00; regular $10.00; 10. Extent and nature of circulation: average number of copies institutional $20.00. each issue during preceding 12 months: total number of copies 4. Office of publication: 17 Murray Street, New York, New York printed (net press run): 6,000; paid circulation: (1) sales through 10007. dealers and carriers, street vendors and counter sales: 0; (2) mail 5. General business office of publishers: 17 Murray Street, New subscriptions: 3,050; total paid circulation: 3,050; free distribution York, New York 10007. by mail, carrier or other means, samples, complimentary, and other 6. Publisher: Health Policy Advisory Center, Inc.; Editor: Ronda free copies: 306; total distribution: 3,356; copies not distributed: (1) Kotelchuck, c/o Health/PAC, 17 Murray St., N.Y., N.Y. 10007; office use, left over, unaccounted, spoiled after printing 2,644; (2) Managing Editor: Barbara Caress, c/o Health/PAC, 17 Murray St., returns from newsagents: 0; total: 6,000. N.Y., N.Y. 10007. Actual number of copies of single issue published nearest to 7. Owner: (If owned by a corporation, its name and address must filing date: Total number of copies printed (net press run): 6,000; be stated and also immediately thereunder the names and paid circulation: (1) sales through dealers and carriers, street addresses of stockholders owning or holding 1 percent or more of vendors and counter sales: 0; (2) mail subscriptions: 2,827; total total amount of stock. If not owned by a corporation, the names and paid circulation: 2,827; free distribution by mail, carrier or other addresses of the individual owners must be given. If owned by a means, samples, complimentary, and other free copies: 301; total partnership or other unincorporated firm, its name and address, as distribution: 3,128; copies not distributed: (1) office use, left over, well as that of each individual must be given.) Private, non-profit unaccounted, spoiled after printing: 2,872; (2) returns from news membership corporation: Health Policy Advisory Center, 17 agents: 0; total: 6,000. Murray Street, New York, N.Y. 10007. Members: Barbara Caress, I certify that the statements made by me above are correct and Oliver Fein, Steven London, David Kotelchuck, Ronda Kotelchuck, complete, (signed) Ronda Kotelchuck, Editor. 2 Kenneth Rosenberg, Elinor Blake, Tom Bodenheimer. sensible, there is considerable reason to oppose the decision to vaccinate non-high- risk people. Vaccination of the entire US 1918 population represents a huge expenditure of The influenza pandemic of 1918 oc- public health resources which at best could curred in two major waves. The first was in prevent non-fatal illness in some. More like- the winter and spring of 1917-18 and was ly, however, the program will divert scarce characterized by high morbidity (50% of public health resources with no significant the people in the world got it) and low effect at all. The vaccination of non-high-risk fatality rates. The second wave started at people was premised on similarities between Fort Devens, Massachusetts on Septem- the new swine flu virus and the virus that ber 12, 1918 and involved almost the many scientists believe caused the great flu entire world in a very short time. Its spread pandemic (world-wide epidemic) of 1918, an was bizarre: it was detected on the same association that is now largely discredited. day in Boston and Bombay but it did not The plan for mass vaccination of the occur in New York until three weeks later. entire population has come under such It did not affect those who had been ill the intensive public attack that some states are previous winter and spring but its effect on already effectively giving it up. Massachu- everyone else was devastating. It may well setts, for example, has publicly stated that have killed more people in a short space of the vaccination of high-risk persons is their time than any other disaster in the history first priority and only after this has of the world. substantially been accomplished will they In all, about 20 million people died, begin to vaccinate others. Given the including 500,000 Americans, in six to slowness of the implementation of the mass eight weeks. A total of 500 million people vaccination program nationally, few non- are estimated to have been stricken by the high-risk persons are likely to be vaccinated disease in the same period. "The number in Massachusetts this year. 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 INFLUENZA AT FORT DIX day. The impact of this pandemic was as great as that of the plague in London, When, in January, 1976, soldiers returned which killed about 2 percent of the to Fort Dix from their Christmas holidays, population per month."(1) they brought with them the usual assortment Much of the 1918 mortality occurred of sniffles, sneezes, runny noses and coughs. among young adults, who rarely die from Army doctors assumed they were seeing the flu, rather than such typical victims of flu usual adenoviruses (common cold viruses), epidemics as the elderly and chronically ill. some of which were severe enough to require In many cases, young persons became ill in hospitalization. They gave little thought to the morning and died that night, often influenza because every Army recruit without any chance to get medical receives a heavy dose of influenza vaccine attention. (2) upon beginning basic training and is revaccinated each year with whatever See References pages 19, 20 influenza strains are prevalent that year.