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

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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. Colonel Joseph Bartley, chief of preven- tive medicine at Fort Dix, called the local civilian population. The county health officer county health officer to warn him that the in turn contacted Dr. Martin Goldfield, adenoviruses might spread to the nearby 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, Morgan town, 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. Jersey, who said that the outbreak sounded that if he missed more than three days of more like influenza than an adenovirus. He basic training, however, he would have to suggested that cultures from the affected repeat it all, so he joined his company on a soldiers be checked by the state lab for the seven mile "forced march" in the snow. influenza type predominant at the moment, Lewis collapsed before the end of the march A/Victoria/75 (so named because it is a Type and was dead on arrival at the base hospital. A influenza strain that was first identified in Most experts, including Colonel Bartley, Victoria, Australia in 1975). think Lewis would have lived if he had stayed Goldfield was right: Fort Dix was having a in bed instead of going on the march. flu epidemic. Most of the nineteen cases for Immediately a large-scale screening was which samples were sent to the New Jersey implemented at Fort Dix and in the labs on January 29 contained the Victoria flu, surrounding community. A/New Jersey/76 but four samples were unusual strains of was isolated in five cases, including that of Type A influenza that could not be identified. Lewis. In another eight cases there was clear The unknowns were sent to Atlanta, Georgia to the Center for Disease Control (CDC), a branch of the Public Health Service of the US Department of Health, Education and Welfare (DHEW). To the amazement of the To the amazement of CDC, they CDC staff, they discovered, on February 13, that this unusual Fort Dix virus was similar discovered that this unusual to one of the first viruses that had ever been Fort Dix virus was similar to isolated, in the 1930s. one o! the first viruses ever This virus had early been identified as very similar to a virus common in pigs (hence isolated. the name "swine flu" virus). What is more, in most locations investigated throughout the world, survivors of the 1918 flu pandemic had antibodies to this virus, leading evidence oi infection by A/New Jersey/76 as scientists to conclude that the 1918 pandemic determined by an increase in antibody levels had been caused by swine flu virus. CDC following the second of two blood tests labelled this new virus strain A/New several weeks apart. In another 500 cases Jersey/76 (Type A virus strain discovered in high levels of antibodies to swine flu virus New Jersey in 1976) and alerted Army were found after a single blood test; these doctors to the possibilities of a "killer" virus cases were concentrated in the same outbreak like that of 1918. companies as the positively identified cases, CDC was particularly concerned because although many of these soldiers had not been the swine flu virus at Fort Dix had been sick. spread from one person to another, apparently because of a recent genetic CDC ORCHESTRATES A RESPONSE mutation of the virus. Virologists had seen 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 New'Jersey and three involved branches of flu that spread from person to person raised /ehe(Puplic Health Service: CDC; the Food the specter of an epidemic of major / and Drug Administration (FDA), represent- proportions. \ed by ~rcs Bureau df Biologies; and the National Institutes of Health (NIH), repre- A SOLDIER DIES 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, to a serious investigation of the swine flu Private David Lewis died of viral pneumonia situation at Fort Dix and a search for cases at Fort Dix. Lewis had had a moderately elsewhere. severe flu-like illness and was told by Army On February 19, CDC made the first public doctors to stay in bed for 48 hours. He knew 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 Biologies, 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 scientists and public health officials searched aggressively for new evidence of the disease. Was 1918 Swine Flu? They found none. No new cases were found at Fort Dix or anywhere else in the US or the In recent years the theory that the 1918 rest of the world. pandemic was caused by the swine Nevertheless, in a March 13 "action influenza virus has also come under attack. memo," Dr. David Sencer, Director of CDC, Three NIH scientists, including Dr. J. recommended a mass vaccination program Anthony Morris and 1976 Nobel prize for all Americans at a total cost of $135 winner D. Carleton Gajdusek, reported in a million. He noted that "the Administration 1969 Science article the details of a study of can tolerate unnecessary health expendi- an isolated Pacific island which had been tures better than it can tolerate unnecessary exposed to only one twentieth century flu death and illness, particularly if a flu epidemic, a late outbreak of the 1918 pandemic should occur." pandemic. They measured antibodies in Sencer's memo was issued on his own the inhabitants' blood and found much initiative. He failed even to consult members higher antibody levels to PR/8 influenza of the CDC's own Advisory Committee of virus than to swine flu virus. PR/8 is an Immunization Practices before sending the A-type virus that has very different surface memo to higher-ups in the Ford Administra- antigens (protein subunits) than swine flu. tion (perhaps because the Committee at its The study concludes, "Our results indicate March 10 meeting had refrained from calling that the virus circulating in the 1918 for such a program, recommending only that pandemic era was more closely related to planning for such an eventuality begin). human type A strains circulating in the middle 1930s than to other known AN EPIDEMIC IS CREATED influenza virus strains, including the virus On March 22, DHEW officials took the of swine influenza."(I) memo to the President. Ford, never known One reason scientists have so long for quick, decisive action, except for the accepted findings that the 1918 pandemic deadly Mayaguez incident, called a meeting was swine flu, according to the same with thirty prominent medical scientists article, is that almost all data were within 48 hours. The scientists, led by Jonas gathered from urban populations. "Al- Salk and Albert Sabin, both of polio-vaccine though antibody to swine influenza occurs fame, and vaccine researchers Edwin very infrequently after a single infection by Kilbourne of Mount Sinai Medical School the PR/8 strain of influenza virus, antibody and Fred Davenport of the University of develops against both swine and human Michigan, recommended a nationwide vac- strains of influenza after repeated im- cination program. munization with the PR/8 strain." Literally within minutes of the panel's Antibodies to swine flu virus may have recommendation, President Ford called a developed simply because of "the broad- press conference to announce the program. ening effect of cumulative infections with "This virus is very similar to the one that human type A strains."(2) caused a widespread and very deadly See References pages 19, 20 epidemic late in the First World War," the President said. "Some older Americans 5 today will remember that 548,000 people administrative funding, but to no avail. They died in this country during that tragic argued that already hard-pressed states period." The only way to prevent a could not allocate additional funds for this recurrence, he concluded, was to vaccinate new program but would be forced to divert "every man, woman and child" in America. money and resources from already under- In the aftermath of President Ford's funded preventive and public health pro- dramatic announcement, with little serious grams like family planning, maternal and debate, Congress enacted the program. child care and tuberculosis and venereal Symbolically, the date was April 12, disease surveillance. thirty-first anniversary of Franklin Roose- velt's death and the day, exactly ten years THE BUBBLE BUBSTS later, that successful results of the polio Initially the decision to launch the mass vaccine trials were first announced publicly. vaccination program seemed sensible given Congress appropriated the entire $135 the little data available. A new flu strain had million requested for the program: been detected, which could be expected to • $100 million for purchase of 200 million lead to a worldwide outbreak (all previous doses of flu vaccine from four drug strains since 1930 had done so). Its virulence companies (Merck, Sharp and Dohme; was apparently confirmed by Private Lewis' Merrell-National; Wyeth; and Parke-Davis); death and by the virus' resemblance to the • $26 million in project grants as seed strain usually blamed for the 1918 pandemic. money to state and local governments to Medical scientists believed that they had develop mass immunization programs; the capability of preventing an epidemic, • $4 million to the National Institute of given their unprecedented lead time in Allergy and Infectious Diseases to expand detecting the virus—perhaps six to twelve research on flu; months earlier than any previous strain. For • $3.2 million to the FDA to certify the such a vaccination program to be effective, vaccine; they felt, it must include healthy young te the adults—the group particularly hard hit by the 1918 pandemic—as well as more Thus three-quarters of the money went to traditional victims of the flu—the elderly and private, profit-making drug companies. The the chronically ill. companies were reimbursed at about 50 The basic medical assumptions behind the program, however—that the flu strain threatened a worldwide outbreak and that it was a "killer" virus—were not borne out. On March 22, the scientists, led During the spring and early summer the fearsome projections of the program's by lonas Salk and Albert Sabin, supporters were undermined by an increas- recommended a nationwide ing accumulation of negative evidence pouring in from many sources and discount- vaccination program. ing the medical rationale for the program. This evidence was persistently discounted or ignored. THE DISEASE DOES NOT SPBEAD cents per dose, roughly the same cost per Despite an intensive search for A/New dose as in earlier flu vaccination programs. Jersey/76, not a single case has been found In contrast, administrative expenses were anywhere in the world since the Fort Dix underfunded: only $26 million—13 cents per outbreak. After the first week in which swine dose—was budgeted for state and local flu was detected at Fort Dix, repeated throat administrative costs. These costs averaged washings at the Army base have turned up 60 cents per dose during earlier vaccination only the common A/Victoria/75. The winter programs, however—more than four times flu season has now passed in the Southern the budgeted amount. Hemisphere and flu centers there have State and local health officials had earlier detected no A/New Jersey/76.(1) Nor have 6 protested the inadequacy of the proposed (Continued on page 10.) Notes From NYCfs 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 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. MUNICIPAL | , , They argued that giving Montefiore effective HOSPITAL 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 and Montefiore concerning operation of State and Montefiore representatives. None NCB. The HHC, for example, backed off its seemed especially worried that the entire previous commitment to cover any debts municipal hospital system was sinking; incurred by Montefiore for patients without rather it was as if the officers on the Titanic third-party coverage (Medicaid, Medicare or had fallen into a poker game with the ship private insurance). and fittings as stakes. A battle of nerves ensued between HHC Meanwhile aboveboard, the public on the and Montefiore. In July, NCB opened its one hand and the worker's unions on the doors to everyone but patients; fully staffed other demanded the hospital's opening. As and operational, the hospital "functioned" the media focused on the costs of delay, at a cost of $2.5 million a month for over community groups protested the lack of three months without admitting anyone. health care and the largest municipal NCB could not admit patients without an workers union—DC 37—threatened citywide operating certificate from the New York action, the HHC filed suit in State Supreme State Department of Health. State officials Court to force State officials to issue the refused to grant such a certificate until the operating certificate. On October 14, State following issues could be resolved: Supreme Court Judge Edward Greenfield • Where would HHC find the anticipated finally ordered the certificate released and $41.6 million needed to operate NCB on October 22, with Montefiore agreeing to a annually? The question was a biting one trimmed-down affiliation contract, North since HHC's expenditures were already Central Bronx Hospital admitted its first running $75 million over its budget. patient. • How could the state allow HHC to add 412 hospital beds in a city already thought to contain 5,000 excess beds? Specifically Disposable Hospital which Bronx hospitals would be eliminated? At least two patients are reported to have • Should the HHC sell NCB to Montefiore, bled to death in recent weeks at the South thus escaping any operating cost or Bronx's Lincoln Hospital as a result of cuts in responsibility at all? Such a suggestion services and battles over its affiliation seemed perfectly rational, to those who contracts and administration. sympathized with the call by financial The New York Times (November 5, 1976) leaders for drastic cutbacks in all city reported that State Health Department services. investigators clearly linked the two deaths to Resolving these and lesser issues involved inadequate facilities and a shortage of weeks of backroom bargaining among City, 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 probable opponent in the next. When Badillo defeated Velez in Septem- installed at NCB (see above) and Albert ber's primary for the South Bronx congres- Einstein College of Medicine continues its sional seat, pressure mounted for Galarce's affiliation with the Bronx Municipal Hospital dismissal. The Health and Hospitals Corpor- Center. With the closing of Fordham ation (HHC) felt obligated to get rid of Hospital, however, Einstein has been forced Galarce. But, like virtually every other recent to share affiliation at Lincoln with Fordham's event involving the public hospitals, firing old affiliate, Misericordia Hospital. Galarce became an ugly and complicated The only Catholic institution in the mix, matter. Misericordia had actively campaigned for the Following a perfunctory and obviously pre- NCB affiliation but lost out to Montefiore. It ordained investigation, HHC accused then insisted on being given Lincoln as a Galarce of mismanagement and summarily kind of consolation prize. Einstein balked. fired him in late October. Galarce refused to Governor Carey and Deputy Mayor John leave. Reports of suspicious fires, gangs Zuccotti came down on Misericordia's side. running through corridors, and takeover of HHC's own Board of Directors voted for the administrative offices by Velez's hench- continuation of the joint affiliation. Finally, men began to circulate. Badillo called for Mayor Beame and Governor Carey overruled "the National Guard to stop the reign of them and Einstein will be phased out of terror". After more than a week of utter Lincoln by June, 1977. chaos, Galarce was finally removed; Lincoln Amidst all this jockeying, the two deaths has since been administered from the HHC's reportedin the emergency room were downtown Manhattan offices. avoidable according to Lincoln's Director of Despite its obvious problems, however, Surgery, Dr. Francisco Suarez. "There is an the new Lincoln remains a plumb to the excellent chance [of more deaths] unless the medical schools and voluntary hospitals real gut problems are resolved," he said. whose affiliation agreements provide much Despite the deaths—not to mention its of the professional staffs in public hospitals. investment of $260 million—the City seems These private affiliates, feeling the fiscal to regard Lincoln, the only public hospital in pinch as well, since where there were four the south Bronx, as a disposable item to be public hospitals in the Bronx, there are now used for ammunition in the increasingly three. Montefiore Hospital is now securely heated wars over fiscal politics.

PROGNOSIS NEGATIVE: CRISIS IN THE HEALTH CARE SYSTEM edited by David Kotelchuck ANEWHEALTH/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 2U postage to: Health/PAC 17 Murray Street New York, New York 10007 hospitalized with A/New Jersey/76 during Swine Flu the Fort Dix outbreak with ten men (Continued from page 9 .) hospitalized with A/Victoria/75. It conclud- ed that "their illnesses were similar but that any of the World Health Organization's 96 A/New Jersey influenza may have been a monitoring stations all over the world ever somewhat milder illness."(6) In a review found A/New Jersey/76. article in the July 3 Lancet, the renowned (A recent case of swine flu in Missouri was Charles Stuart-Harris summarizes the influ- documented by increased swine flu antibody enza epidemics of the last forty years and level. The lack of spread despite extensive concludes: "This experience of pandemic searches among contacts makes it likely that influenza due to a virus of antigenic this man's illness was due to the classical composition completely different from its pig-to-man swine flu, not the Fort Dix swine precursors thus gives no ground for a belief flu, which spread from person to person. that the Swine-like virus will behave in an This was not an example of seeding but unusually virulent way. Nor can the human another variety of swine flu. This variety's population of 1976 be regarded as analogous virulence appears to be low judging from the to that of the Western World of 1918 after 4 man's relatively mild symptoms.) years of an exhausting war."(7) This absence has important implications Even the apparent resemblance of A/New because no pandemic of flu has ever Jersey/76 to the earlier swine flu strain in occurred without being preceded by at least laboratory tests is weak evidence for its several local outbreaks in various parts of the virulence.(8) A/New Jersey/76 was identi- world, according to British flu expert Dr. fied and typed because it produced the same David Tyrell.(2) Tyrell's statement is sup- antibodies as the original swine flu virus— ported by Dr. W. Charles Cockburn, Director i.e., it has very similar surface antigens. But of the Communicable Disease Division of the this similarity sheds no light on the internal World Health Organization. Currently none antigens, which determine a flu strain's of this "seeding process" is evident.(3) The virulence. Many scientists noted, for exam- failure of A/New Jersey/76 to spread led two ple, that flu strains with surface antigens researchers to state, in the lead article in similar to the 1918 flu virus continued to be Lancet, one of Britain's most respected common around the world until 1928 but medical journals, "It seems possible that the during those ten years they rarely killed outbreak in the U.S.A. was an isolated event healthy adults or even produced particularly and that the virus will not become severe symptoms. established in man."(4) Throughout the swine flu controversy There is a possibility that A/New much public confusion has arisen from the Jersey/76 has been detected early in its assumption that a pandemic implies great natural cycle compared to previous strains virulence. This, of course, is not necessarily and that it will "seed" later and strike with true: there can be world-wide spread of full force in the winter of 1977-78. If so, low-virulence influenzas. So far there is however, a vaccination program this year neither evidence of a world-wide swine flu will have little impact on the seeding process outbreak nor any solid evidence of swine flu and the whole vaccination program will have virulence. to be repeated next autumn, since flu vaccinations give immunity for only six to eight months. THE VACCINE ITSELF: HOW EFFECTIVE? NOT A KILLER VIRUS 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 A/New Jersey/76 is less virulent in man responsible for carrying out the program, not than A/Victoria/75.(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-Side-Effects Side Effects

When three elderly heart patients died of the deaths were autopsied, showing on October 11, hours after receiving the flu causes of death within the normal range vaccine in a Pittsburgh clinic, it produced for old people who die suddenly: a lot of headlines throughout the country and heart attacks and one ruptured aneurysm. vaccinations dropped precipitously. Head- The absence of deaths in the first hour af- lines featured daily body counts. The total ter vaccination indicates that none was who died within a few days of receiving due to allergic reactions, which would oc- bivalent (swine and Victoria) vaccine cur within minutes of vaccination. (1) One reached 38 within the first week. cardiologist hypothesized that the stress of Although later investigation showed the waiting in line, getting the injection or any deaths to be coincidental, as government other stress might cause a person already officials initially asserted, the credibility of on the verge of having a heart attack to do the mass vaccination program had been so a few hours earlier. Fever is a classic seriously weakened by trying to pass off type of stress that produces such a this initial educated guess as fact. When response, but the deaths do not correlate 2V2 million high-risk persons are vac- with the time when fever side-effects of the cinated in one week (only bivalent vaccine vaccine should occur. was being given at that time) a certain The most important effect of the hysteria number can be expected to die suddenly of has been to decrease the number of people other causes. CDC analysis of the 38 who will get vaccinated this year, a serious reported cases showed that the number of problem for high-risk people who really do deaths probably reflected the extent to need the vaccine—especially against which physicians connected deaths of A/Victoria/75. their patients with vaccination. Over half See References pages 19, 20

Cooper, DHEW Assistant Secretary for vaccine) of the subjects between 18 and 24 Health, says that government experts had adequate antibody responses.(11) "agree that, in recent years, flu vaccine has Government reports and many scientists been up to 90 percent effective when the have equated antibody response with vaccine infecting virus matches the virus used in the effectiveness, that is, the extent to which the vaccine. They anticipate similar performance vaccine will prevent a person from becoming from the swine flu vaccine."(9) Similarly, ill after exposure to the naturally occurring CDC has estimated that "at least 70% of the flu virus. This equation, however, has been individuals receiving the A/New Jersey questioned by some scientists. influenza vaccine will be fully protected Dr. J. Anthony Morris, a former section against that strain for the coming fall and director of FDA's Bureau of Biologies, winter influenza season."(10) argues that "Flu vaccine made from Governmental optimism was boosted by inactivated particles, like the one now being an extensive study sponsored by the Public manufactured, produces "the wrong kind of Health Service and reported in a June 21 immunity.' It elicits systemic antibody conference. 5,200 volunteers were injected [immune globulin G] that can be measured in with the flu vaccine, mostly A/New the blood, but does not produce the local Jersey/76 and/or A/Victoria/75, in the antibody [immune globulin A], in the lungs dosages being recommended. Antibody and nose, which is needed to protect against levels to the vaccine before and two weeks infection by the flu virus." Morris estimated after the vaccination were measured. About the effectiveness of the flu vaccine against 90 percent of the subjects over 25 showed a A/New Jersey/76 to be only about 20 large antibody response, although only 28 to percent. When the Government Accounting 58 percent (depending on which company's Office, a watchdog agency of the US 11 Congress, asked other scientists to assess presence of symptoms (fevers and respira- the vaccine's effectiveness, the estimates tory symptoms) but an 80 percent efficacy ranged from 25 to 73 percent.(12) rate when they defined influenza by blood Public criticism from within the govern- antibody levels. (17) Another study done ment infuriated Morris' superiors. In the during the Hong Kong flu epidemic of 1968 early 1970s, Morris and his attorney, James concluded that: "The results indicated that S. Turner, had been key figures in the optimally constituted influenza vaccines instigating Congressional hearings on the at standard dosage levels have little, if any, management of federally coordinated vac- effectiveness." (18) In the last analysis, it is cination programs.(13) The result of the clear that there is simply not enough data to hearings was' a transfer of responsibility for evaluate the efficacy of influenza vaccines, regulation of vaccine safety and efficacy to especially those developed during the past the FDA and the creation within FDA of the Bureau of Biologies. 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 vaccine recipients to become more ill than non-vaccine 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 percent. But there have been very few few years, which have not been field-tested adequate studies of the protective value of at all. vaccination against a real epidemic. One of the few good prospective studies on the 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 more serious illness later. Generally, the were followed by a booster of the same dose. 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 process is imperfect, some egg proteins percent of those over 24 years old had such remain in the final product. For this reason symptoms, although it is reasonable to public health officials have routinely alerted assume that a much larger number of people egg-allergic people not to be vaccinated. experienced milder symptoms. Although there have never been any The Conference also reported an unac- reported deaths from allergic reactions to ceptably high rate of side effects in children earlier influenza vaccines, the report of the aged three to ten (they did no testing of June 21 PHS Conference lists five separate children under three). A two-dose regimen individuals whose reactions to the vaccine for children was more recently approved, but were considered to be allergic.(20) the matter is of no great concern, since children do not get particularly sick from flu. THE SABIN SWITCH The high level of side effects was a setback, Perhaps the most telling blow was struck however, for those scientists who had hoped by Dr. Albert Sabin, who publicly abandoned to actually prevent an epidemic from the program in early November. Sabin, like occurring by vaccinating "every man, so many others, went along with David woman and child," since children are major Sencer's initial memo to President on the carriers of epidemics like the flu. Mean- basis of available evidence at the time. He while, young adults (18 to 24) had side effect has sufficient stature, due to his pioneering rates intermediate between children and work in developing the polio vaccine, that his older adults.(19) opposition to Sencer's plan would have cast a The flu virus is routinely grown in shadow over the program at its inception. fertilized eggs. Because the purification Sabin's support certainly cannot be at- tributed to dependency on federal research monies, since his prestige has guaranteed funding from numerous sources. Informed Consent? Sabin began to rethink his position as negative information on the mass vaccination The reality of side-effects from vaccines, program began to accumulate. His doubts some of which are quite severe, though grew after the June 21 meeting, when the seldom fatal, forces the government to poor antibody response of those under 25 led deal, at least in a limited fashion, with the 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 Then, on November 5, he stated publicly that C* contained a pro-forma requirement that the possibility of a swine flu epidemic is 1 the government vaccinators get approval "now practically negligible."(21) J from the National Commission for the S Protection of Human Subjects of Biomedi- / cal and Behavioral Research (a DHEW ALTERNATIVES [ watchdog Commission on the civil rights of \ patents and research subjects) for their The speed with which the federal \ informed consent procedures. This proved government had to make a go or no-go no small matter: the vaccinators had decision on the mass vaccination program printed up 60 million consent forms seemed to preclude the possibility of public labelled "Registration" forms. The Na- discussion of alternative programs. As noted tional Commission seriously challenged earlier, CDC identified A/New Jersey/76 on the intentionally misleading character of February 13 and made the first public the forms and suggested that they be announcement of its discovery on February discarded, but PHS officials have proceed- 19. Very soon thereafter the Bureau of ed to use these forms anyway. By ignoring Biologies set April 1 as the target date by the Commission's challenge, they are which a decision had to be made. Five or six skirting at least the spirit if not the letter of 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 for public discussion. 13 Swine Flu Insurers: Legion Heirs The mass vaccination program had This landmark decision had its scarcely been announced before the greatest impact on the insurance drug industry began voicing fears about companies, now faced with coverage of obtaining insurance coverage for the a large, potentially open-ended liability. production of vaccine. The fact that Since 1975, these insurance companies such coverage is necessary has a have been threatening to get out of the history in the 20-year-old tension vaccination insurance business, in what among government, drug companies seems to be part of a long-term strategy and insurance companies over vaccine to abandon the medical malpractice safety and liability for public protection field altogether. Argonaut, for one, has in their use: openly stated its interest in getting out • In 1955 a batch of polio vaccine of the malpractice field; in late 1974-75, made by Cutter Laboratories and the whole industry began pressuring contained inadequately inactivated for huge increases in malpractice rates. polio virus caused ten deaths and 192 Despite variable success, the industry cases of paralytic polio. (1) as a whole was disappointed and • In 1961, Dr. Bernice Eddy, Division continued to express its disillusionment of Biologic Standards (predecessor of with malpractice coverage. the FDA's Bureau of Biologies), On April 12, the day the House of showed that some of the polio vaccine Representatives passed the $135 million being used was heavily contaminated funding bill for mass flu vaccination, with "SV-40," a virus that had been Merck & Co. requested relief from shown to produce cancer in several claims arising from adverse reactions to animals. (2) the vaccine. Over the next few months • Finally, last year, a federal court drug companies repeatedly told DHEW, found (Reyes vs. Wyeth, 1975) a drug CDC and the press that their insurance company liable when a child got polio carriers were not offering coverage for from polio vaccine. Since no "doctor- liability claims arising from swine flu patient" relationship existed, thus vaccine production. The most frequent making "informed consent" impossible excuse was the fear that anyone who in the public clinic where the vaccine got as much as a cold after vaccination was administered, the company was would file a "nuisance" suit, costing a held responsible for informing the lot of money to defend in court even if child's parents that one possible the company won. At no time did drug complication of polio vaccination is the or insurance firms publicly state development of polio. qualms about any dangerous side-

Further limiting policy alternatives is the implemented. The stockpiling strategy is a lack of an extensive, coordinated public questionable one, however, since the main health system in the US to quickly implement delay in any future vaccination program such a vaccination program. In European would stem from the bureaucratic bottleneck industrial countries, for instance, the of administration rather than from delays in start-up time would be shorter because vaccine production. The 1918 flu spread neighborhood and workplace health delivery rapidly and erratically; even the less virulent mechanisms are generally already in place. Asian and Hong Kong flus spread worldwide The only alternative extensively discussed within a few weeks. Since it takes about two since President Ford's announcement of the weeks after vaccination for the vaccine to program has been production of the vaccine become fully effective, the disease could and stockpiling it until a, possible reap- therefore spread throughout the population pearance of A/New Jersey/76—at which before a mass program could be imple- 14 time a mass vaccination program might be mented. effects of the vaccine. ise to inform patients of vaccine risks Historically, however, there have and obtain their consent before they been few liability suits over flu vaccines took the shots."(3) and the cost of a losing court case is Meanwhile, the drug companies usually borne by the loser of the case. continued production but refused to sell In fact, unless one bears in mind the it to the federal government until the insurance companies' desire to get out liability issue was resolved. The resolu- of malpractice coverage, the level of tion came on August 3, when "amid industry panic is difficult to under- initial reprots that swine flu was among stand. In a similar vein, physicians, the diseases being considered as the hospitals and clinics were being told by cause of the mysterious illness that the insurance companies that they invaded a meeting of American Le- would not be covered by normal mal- gionnaires in Philadelphia, the Com- practice insurance if they participated merce Committee's Health Subcom- in the mass campaign, yet there is no mittee quickly reported a swine flu equivalent of the "Reyes case" for liability bill and sent it to the full Com- these private facilities and they have no mittee. Under the bill, anyone who responsibility beyond normal medical claims injury from the program would care liability. have to sue the federal government for Most of July and August was con- damages. Should the court award sumed with multiple delays, with the damages for negligence, the federal struggle continuing between the insur- government could in turn sue the ance companies and the federal govern- negligent party to recover the awarded ment about liability insurance. The damages. A key provision of the bill carriers asked Congress for legislation states that hospitals, physicians, para- exempting them from lawsuits result- medical personnel and distributors ing from adverse reactions and limiting would be given this federal liability liability exclusively to claims that could coverage—provided they did not prove negligence in vaccine production. charge for administering the flu The House Health and Environment vaccine." (4) Wisely seizing upon the Subcommittee, chaired by Paul G. panic created by the government's own Rogers, refused, with the backing of speculation about the Legionnaires' HEW, since "such a government Disease, the drug and the insurance indemnity could become a precedent of industry—unlike the American public far-reaching consequence for other —got even more than they had vaccines and drugs. DHEW officials originally requested. would actually prefer a less-drastic solution: The government would prom- See References pages 19, 20

The real alternative, a high-risk-only health projects that are desperately needed program, would save the amount of money and seriously underfunded. The real bene- that was going into production of vaccine for factors of the $80 million now are the drug non-high-risk people. The cost of the 40 companies. million doses to vaccinate all high-risk Americans would be about $20 million, RESISTANCE TO CHANGE compared to the $100 million now being If the decision to vaccinate all Americans spent for 200 million doses. The $80 million were simply a medical decision, no doubt the saving could have been spent on finding and mass program would have been abandoned vaccinating high-risk people—in recent long ago in favor of a reasonable alternative, years, an average of only 10 million people such as vaccinating only high-risk people. (one-fourth) of all high risk people have Medical decisions never occur outside a actually received flu vaccine. Or it could have social context, however, especially when been spent on any of a dozen other public they affect entire populations. 15 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 Once the Ford Administration, following patients they will see in their practices. Some recommendations of public health officials are volunteering in free public vaccination and prominent medical scientists, decided to programs; most, however, will simply collect proceed with the program, a whole series of routine office fees. Although not permitted interests were unleashed which stood to to charge patients for the cost of the vaccine, benefit from it. These, combined with the which comes free from the government, fees Administration's election year imperatives, will be charged for other nominal services. were so powerful in stabilizing the program • Large Employers: American business- that it continues despite a preponderance of men, especially those from large corpora- medical evidence against it. Among these tions, generally favor the mass vaccination interests are middle-level public health program. Their most obvious interest lies officials, drug companies and private with non-high-risk Americans, for whom the physicians, and large employers in general. program is the most questionable, since • Public Health Officials: Emerging from virtually all productive workers fall into that the often routine and thankless world of category. The program, from their vantage public health administration, many officials point, can be counted on to reduce are still wide-eyed at the sudden glare of absenteeism during the winter, thus en- publicity produced by the swine flu program. hancing company productivity and profits. Dr. Harry Meyer, Director of the Bureau of The Hong Kong pandemic of 1968-69 was Biologies, put it clearly: "In the world I deal estimated to have cost $3.9 billion in medical with every day, there are so many things you care, industrial absenteeism and future do that are not terribly interesting, but which earnings of those who died. Corporate are called 'real chores.' To have a challenge executives are all too happy to have the of something that is a real public health government (with a tax base that dispropor- 16 interest is really stimulating."(22) From a tionately takes from the working classes) give them a $135 million insurance policy exposure than healthy persons. against potential damage to their earnings. In 1918 the world was well into its fourth • The Ford Administration: The key year of the worst war it had ever decision to go ahead with the mass program, experienced. There is no way to know what and the later necessity to defend it against all would happen if the identical virus were to criticism, came, of course, from the Ford reappear today, but it is highly unlikely that Administration. Noted for having taken no it would wreak such destruction as it did initiative on any major health program (see then. In 1918, world nutrition levels were BULLETIN, September/October, 1976), the lower, housing conditions everywhere were swine flu program might take the edge off worse, and the effects of war, stress and criticism that might arise during the fatigue are incalculable. Incredibly, how- campaign. ever, scientists and public health officials At first blush, it was a no-lose program for have generally failed to consider the President Ford: if there was an outbreak of question of host resistance in the case of swine flu, he had acted to protect the A/New Jersey/76. American people; if no outbreak material- ized, he could still say that he had protected CONCLUSION: them. The program became a no-win one, MEDICAL OVERKILL however, with few benefits, many rip-offs, If the US economy were reasonably growing cynicism and several deaths ap- healthy and there existed a real national parently caused by the vaccine a few weeks commitment to meet the health care needs of before the Presidential election. all the people, the medical overkill associat- WHAT IS AN EPIDEMIC? ed with the swine flu program and its millions of dollars in wasted resources If there are any lasting benefits from would be no great tragedy. With government Ford's swine flu extravaganza, it may come budgets tight and health care programs from the questions it raises about the being cut back, however, especially pre- limitations of modern clinical medicine. The ventive and primary care programs, misal- failures of the mass vaccination effort, along location of resources on such a scale is tragic. with the unsolved mystery of the Legion- In Fiscal 1975, the total federal outlay for naires' disease, bring unprecedented public prevention and control of health problems attention to a growing controversy about was about $1 billion, just three percent of the those limitations. federal health budget. (26) Thus the $135 Based on a medical model that seeks a million associated with the swine flu technical answer to every problem, modern program represents about thirteen percent of clinical medicine largely ignores the social all federal expenditures for prevention and and emotional stresses so critical in control. It rivals the $170 million spent producing major killer diseases such as heart annually for all occupational health activi- disease, stroke(24) and cancer.(25) ties, and far exceeds the $30 million yearly An unanswered question about influenza budget of the National Institute for Occupa- is the extent to which illness is caused by the tional Safety and Health, the chief agency for 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 The Hong Kong pandemic of very little work has been done from this perspective on influenza. At the most 1968-69 was estimated to have obvious level, the flu is much like the cost $3.9 billion in medical common cold: some people who are exposed to the virus become ill and others do not and care, industrial absenteeism the extent of illness is not simply proportion- and future earnings of those al to the number of germs that have entered the body. In the most extreme cases, who died. malnourished and other debilitated persons will become far more ill from the same 17 education, self-government, shifting of tax Epidemic: Germs or burden from poor to rich, creation of agricultural cooperatives, etc."(l) Social Factors? Virchow's suggestions represented the thinking of the anti-contagionists, who said There is a long history of conflict that disease came from local conditions between those medical people who feel and opposed quarantines (hence obtaining that diseases and epidemics are caused support from commercial interests "who solely by germs and those who feel they are did not want ports tied up.") They were caused by economic, social and psycho- opposed by the contagionists, "who took logical factors that make the host less the position that disease comes from the resistant to germs around them. "In 1847 outside, needs quarantine and related Virchow was sent by the Prussian bureaucracy. . . . When the germ theory government to investigate a typhus was developed, it would seem natural . . . epidemic. . . . Virchow's recommenda- that germs were also a necessary but not tions . . . called for full employment, sufficient condition for disease production better nutrition and sanitation, raise in —but . . . germs became heralded as . . . wages, separation of church and state, the sole cause of disease production to the restoration of native language, public total exclusion of social factors."(2)

See References pages 19, 20

occupational health research in the US renewed emphasis on traditional childhood government. It is about twice the total spent vaccination programs is still needed in inner on noise control and abatement (27) and cities and rural areas. It also diverts dwarfs the few million dollars spent yearly attention and resources from those aspects of by the government on its anti-smoking the field vitally important in the effort to efforts. bring under control such present epidemics The swine flu program is a diversion in as heart disease, cancer and stroke. The another way, as well. Touted by its tragedy of the swine flu program, then, is not supporters as a major preventive health so much in what it does as in what urgent program, it was in fact a narrowly defined tasks it diverts us from. preventive health program, within a tradi- —Kenneth D. Rosenberg 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 References disease control, a strategy firmly situated I.Walter Sullivan, "Experts in Europe Question U.S. within this medical model. Plan for Mass Flu Shots," New York Times, June 9, Recently, under the impact of efforts to 1976, page 1. 2. Cited in testimony of Sidney Wolfe and Anita Johnson prevent heart disease, cancer and stroke, of the (Washington, DC) Health Research Group before the House Health Subcommittee, June 28,1976. there has been increased emphasis on 3. Sullivan, ibid. improved nutrition, physical conditioning, A. A.S. Beare & J.W. Craig, "Virulence for Man of a Human Influenza—A Virus Antigenically Similar to anti-smoking efforts, and control of environ- 'Classical' Swine Viruses " Lancet, July 3, 1976, page mental and occupational hazards. Some are 4. 5. Idem. even seeking a relation between the onset of 6. Michael Hattwick, Richard O'Brien, Charles Hoke & Walter Dowdle, "Pandemic Influenza, The Swine Influ- disease and the physical and emotional enza Virus and the National Influenza Immunization stresses of late twentieth-century US capi- Program," CDC National Influenza Immunization Program, Pamphlet Number 6. talism (e.g. see 28). The focus of the swine 7. Charles Stuart-Harris, "Swine Influenza in Man," flu program emphasizes that which is most Lancet, July 3,1976, page 32. 8. Editorial, "Planning for Epidemics," Lancet, July 3, 18 traditional in preventive health, although 1976, page 25. 9. Philip M. Boffey, "Swine Flu Vaccination Campaign: Consumer Reports, "Swine Flu: Did Uncle Sam Buy a Pig in a The Scientific Controversy Mounts," Science, 193: 560, Poke?" September, 1976, pages 495-498. August 13,1976. Alfred W. Crosby, Jr., Epidemic and Peace, 1918 (Westport, 10. "Influenza in the United States: Rationale for Mass Connecticut: Greenwood Press, 1976). Immunizations in 1976," CDC National Influenza Immunization Program, Pamphlet Number 5. C.C. Dauer and R.E. Serfling, "Mortality from Influenza," 11. Public Health Service, "Transcript of Proceedings: American Review of Respiratory Diseases, 83 (Part 2): 15-28 (1961). Meeting on Testing of Influenza Vaccines," June 21, Douglas Gasner, "Swine Flu: The National Threat That Wasn't," 1976, page 32a. Medical Dimensions, September, 1976, pages 19-26. 12. Robert Pear, "Scientist Says U.S. Fired Him For Criticizing Flu Shot Plan," Washington Star, July 25, A.A. Hoehling, The Great Epidemic (Boston: Little, Brown & 1976, page A-19. Company, 1961). 13. "Consumer Safety Act of 1972," Hearings before the Arthur Levin, "The Swine-Flu Plan: A Health Program in Search of Subcommittee on Executive Reorganization and Gov- a Disease," New York, April 26,1976, pages 57-64. ernment Research before the Committee on Govern- ment Operations, US Senate, April 20-21 & May 3-4, Charles S. Marwick, "Swine Flu Immunization: 'Go' At Last," 1972, pages 429-824. Medical World News, September 6,1976, pages 60-72. 14. Philip M. Boffey, "Federal Vaccine Agency: Critic Metropolitan Life Insurance Company, "Mortality from Influenza Fired After Bitter Conflict," Science, 193: 384, July 30, and Pneumonia," Statistical Bulletin, September, 1976, pages 3-7. 1976. "Transcript of Proceedings: Meeting on Testing of Influenza 15. Cited in "Consumer Safety Act of 1972 Hearings," op Vaccines," June 21,1976, 201 pages. cit., page 773. Dr. Morris says that the sailor study is cited in a letter from the ship's doctor, Dr. Weibenga, Donnel Nunes, "The Great Flu Epidemic of 1918," Washington to John Seal, Director of Research of National Institute Post, May 23,1976, pages C1 & C5. of Allergy and Infectious Diseases and that the John Powles, "On the Limitations of Modern Medicine," Science, industrial worker study is cited in a letter from the tele- Medicine and Man, 1:1-30 (1973). phone company to him. 16. John E. Craighead, "From the National Institutes of Judith Randal, "The Big Swine Flu Snafu," New York Daily News, Health: Report of a Workshop: Disease Accentuation August 23, 24, 25,1976. After Immunization with Inactivated Microbial Vac- Boyce Rensberger, "U.S. Aide Doubts A Heavy Flu Toll," New cines, Journal of Infectious Diseases, 131: 749-754, York Times, July 2,1976, pages A1 & A8. June, 1975. 17. A. Sugiura, et. al. , "A Field Trial for Evaluation of the Boyce Rensberger, "Flu Vaccine Drive Meets Snags That Could Prophylactic Effect of Influenza Vaccine Containing Limit It," New York Times, July 23,1976, pages A1 & A22. Inactivated A2/Hong Kong and B Influenza Viruses," Richard M. Restak, "Flu Shots for 200 Million?" Washington Post, Journal of Infectious Diseases, 122:472-478, December, May 23,1976, pages C1 & C4. 1970. Harold M. Schmeck, Jr., "First Flu Shots Given in Test of Vaccine 18. S.C. Schoenbaum, S.R. Mostow, W.R. Dowdle, M.T. for Mass Use Against Swine Virus," New York Times, April 22, Coleman & H.S. Kaye, "Studies with Inactivated 1976. Influenza Vaccines Purified by Zonal Centrifugation: Efficacy," Bulletin of the World Health Organization, Harold M. Schmeck, Jr., "Flu Shots 4 Weeks Apart Found Safe for 41:535(1969). Those 3 to 18 Years Old," New York Times, October 23, 1976, page 19. Center for Disease Control, "Recommendation of the 1. Public Health Service Advisory Committee on J.W.G. Smith, W.B. Fletcher, P.J. Wherry, "Future Prospects for Immunization Practice: Influenza Vaccine," Morbidity the Control of Influenza by Immunoprophylaxis and Choice of and Mortality Weekly Report, 25: 221, July 23,1976. Groups for Routine Vaccination," Postgraduate Medical Journal, 20. Public Health Service, op. cit., pages 39, 43, 44 and 98. 52: 399-404, June, 1976; the entire issue is devoted to Influenza 21. Albert B. Sabin, "Washington and the Flu," New York Vaccines. Times, November 5,1976, Op Ed Page. 22. Philip M. Boffey, "Anatomy of a Decision: How the Jonathon Spivak, "Shot in the Arm?: Program to Inoculate All Nation Declared War on Swine Flu," Science, 192: Americans for Flu Appears to be Ailing," Wall Street Journal, June 636-641, May 14,1976. 18,1976, pages 1 &27. 23. John Irvin, Director of Ohio's swine flu vaccination Michael Steinberg, "Swine Flu Vaccine: For the People or For the program, quoted in "Ready and Waiting: Flu Drives Profiteers?" MCHR News, Vol. 1, No. 1, September, 1976. Are All Set to Roll—If the People And Vaccine Show Charles Stuart-Harris, "Pandemic Influenza: An Unresolved Up," Wall Street Journal, August 4,1976, page 28. Problem in Prevention," Journal of Infectious Diseases, "\22: 24. Joe Eyer, "Hypertension as a Disease of Modern 108-115(1970). Society," International- Journal of Health Services, 5: 539-558 (1975). Lawrence Wright, "Sweating Out the Swine Flu Scare," New 25. John Cairns, "The Cancer Problem," Scientific Ameri- Times, June 11,1976, pages 29-38. can, November, 1975, pages 64-78. Barbara Yuncker, "Ford's Flu Shot Campaign: How Safe? How 26. "Special Analyses, Budget of the US Government, Necessary?" New York Post, April 24,1976. Fiscal Year 1975," US Government Pringing Office, Washington, DC, page 137. 27. Ibid., page 243.

Box References

Additional references 1918 (page 3)

Howard Berliner & J. Warren Salmon, "Politics of Prevention: 1. Louis Weinstein, M.D., "Influenza—1918, A Revisit?" New Swine Flu, the Phantom Threat," The Nation, September 25,1976, England Journal of Medicine 294:1059, May 6,1976 pages 269-272. 2. Idem. 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 Was 1918 Swine Flu? (page 5) Magazine, Septembers, 1976, pages8-31. 1. Paul Brown, D. Carleton Gajdusek, J. Anthony Morris, "Virus Jane E. Brody, "Influenza Virus Continues to Keep Scientists of the 1918 Influenza Pandemic Era: New Evidence about Guessing," New York Times, July 23,1976, page A22. its Antigenic Character," Science-\66:117-119, October 3,1969 Bureau of Biologies, "Panel on Review of Viral Vaccines and 2. Ibid. Rickettsial Vaccines," Seventeenth Meeting, June 22,1976. Avail- able on cassette tape only; no transcript was prepared. Non-Side-Effects Side Effects (page 11) Alexander Cockburn & James Ridgeway, "Is Death at the Door- step? Journal of the Plague Scare," The Village Voice, October 25, 1 Telephone interview with Dr. Craven, CDC National 1976, pages 14-15. Influenza Immunization Program, October 27,1976. 19 Swine Flu Insurers: Legion Heirs (page 14) Epidemics: Germs or Social Factors? (page 18)

1 Nicholas Wade, "Division of Biologic Standards: In the 1. Howard Berliner, "Notes on Historical Precursors of Materialist Matter of J. Anthony Morris," Science, February 25, Epidemiology," Health Marxist Organization Packet #7, April, 1972. 1976; available from Health/PAC. 2 Nicholas Wade, "Division of Biologic Standards: 2. Ibid. 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.

HMO PACKET No. 2 Materialist Epidemiology

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20 cause many doctors cannot or will not wait this length of time to be paid, the factoring ban Vital Signs will result in more doctors refusing to take Medicaid patients. Thus by dealing with THE MEDICAID BITE the symptom rather than the cause of the problem, Medi- An HEW-sponsored Rand caid reform penalizes the Corporation study in New York recipients. City suggests that medical (Modern Healthcare, care may be a major cause of October 1976) families moving onto the welfare rolls. Short-term wel- fare families (on welfare for less than three years) use 50 percent more Medicaid ser- NATIONAL HEALTH vices than do long-term wel- INSURANCE COSTS fare families, according to the If recent months have failed study. The study shows Medi- to produce legislative activity caid to be the second largest on the national health insur- welfare expense, accounting ance issue, they have produc- for one-quarter of all welfare ed studies, some of them expenditures. Each year, the influential. One of these, a typical welfare family (3.3 Rand Corporation study con- persons) receives an average ducted by Bridger M. Mitchell of $1900 in direct welfare and William B. Schwartz, was assistance, $1600 in Medicaid published in Science on May financed health care, $1500 in 14. It found the cost impact of shelter allowances, $500 in four major bills (Long-Ribicoff, food stamps, $460 in non- Kennedy-Labor, Nixon, and welfare earnings and $128 in Kennedy-Mills) to be surpris- social services. ingly similar in many respects. (American Medical News, Costs to middle and upper October 4,1976) income families, for instance, were similar for all four measures with the exception of MEDICAID REFORM: the Kennedy-Labor bill, which PENALIZING THE PATIENT costs substantially more for In response to the growing upper income families. Simi- storm over Medicaid fraud, larly, the cost to families with HEW has acted to ban factor- incomes under $15,000 was ing, a widespread practice in very similar for all four bills the Medicaid program. Fac- with the exception of the old toring firms immediately ad- Nixon-CHIP bill, which cost vance a physician money owed substantially more for low income families. Policy makers in Medicaid claims less a fee hope this study will form the (often substantial). These basis for a new compromise claims are held until they are measure. paid by Medicaid and the firm 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- fringe benefits. The settle- tionally known expert on sociation plan, spearheaded by ment, far below that recom- asbestos hazards, suggested Al Ullman, chairman of the mended in the preceding that the high levels might be House Ways and Means Com- months by a federal mediation caused by wear-and-tear on mittee, at a cost of $200.4 commission, was characteriz- auto brake linings and clutch billion. Following it in cost are ed by Mel Foner, 1199 execu- plates from local cars. Kennedy-Labor, $200.2 bil- tive secretary, as "a bitter Two amateur rockhounds, lion; the American Medical disappointment to our mem- Don Maxey and Raymond Association bill, $196.6 billion; bers and a major setback for Kent, school teachers in sub- the old Nixon-CHIP plan, future labor peace in the urban Maryland, were skepti- $189.3 billion; the health in- voluntary hospitals." cal. They thought that the surance industry bill, $189.1 (New York Times, cause was natural asbestos in billion; and Long-Ribicoff, September 16,1976) the serpentine rock used $188.1 billion. Even without widely on D.C. roads and passage of a national health driveways and mined at a large insurance measure, health HILL-BURTON quarry in Rockville, Md. As costs are expected to reach AND FREE CARE cars rode over the rock, they $180.2 billion by 1980, the year believed, it disintegrated and for which costs are projected. Hospitals required to pro- released asbestos fibers into Trapnell found benefits of the vide free care under the the air. To check their theory, Kennedy bill to be by far the/ Hill-Burton program must now they took samples from the broadest. post mjiliilingual signs or quarry and, under the largest distribute written notices stat- magnification of a student's (American Medical News\ ing whether the hospitals' free April 17,1976;] microscope, saw asbestos fi- care obligations have been met bers. The two contacted Dr. New York Timesi and, if not, when free care is October 18,1976? Arthur Rohl, an associate of available. This results from Selikoff at Mt. Sinai, who new HEW regulations which confirmed their findings. In also require that decisions August the four announced concerning free care be made ARBITRATION BINDS their finding to D.C. officials before a patient is treated. In for local action. HOSPITAL WORKERS the past hospitals were allow- ed to write off bad debts to (The Washington Post, The bitter eleven-day strike August 11, 1976) of 40,000 nonprofessional meet free care obligations. health workers represented by Hospitals which have received District 1199, National Union Hill-Burton construction of Hospital & Health Care grants must provide 10 percent Employees, against 57 New of the grant monies in free ...SPEAK NO EVIL York City voluntary hospitals care; those receiving Hill-Bur- A Committee of the Phila- and nursing homes last July ton loans must provide three delphia County Medical Socie- has resulted in an equally percent of operating costs over ty conducted an eight-year bitter settlement brought a 20 year period in free care. study of hospital deaths be- about by binding arbitration (Medical World News, lieved to be caused by mal- accepted to finally settle the October 17,1975) practice, reports the New York strike. Retroactive to July, Times (October 4, 1976). present wages were frozen for Fearful of lawsuits, the Com- six months. Subsequently mittee never kept records, workers will receive a 4% SCIENCE BY THE PEOPLE disciplined doctors or notified percent wage increase which Last year high levels of the State Board of Medical will not become part of base asbestos were found in the air Education and Licensure of its pay, now a minimum of $9,412 throughout the Washington, findings. At most doctors were a year. The union had asked for D.C., metropolitan area; resi- sent "instructional" letters. a $9.95 a week wage increase, dents have been understand- "A lot of people were . . . a one-year contract, larger ably upset ever since. At the very, very fearful that there pensions and vacations, in- time, Dr. Irving Selikoff of Mt. was an element of malpractice 22 creased sick leave and other Sinai Medical Center, a na- here that we had to be careful of," commented the Commit- fiscal year 1977 was enacted to a maximum of $200 million tee head. The Committee was into law September 30 when by 1980. NHSC sends young disbanded two years ago. Congress overrode a Ford doctors to medically under- veto. The bill exceeded the served areas in return for Ford Administration request cancellation of educational OLD COSTS, NEW FORMS by about $4 billion. Attached to debts. The measure takes To counter criticism of the bill was an amendment effect next October. hospital cost increases, the banning Medicaid payment for (New York Times, American Hospital Associa- abortions except when the life October 14,1976; tion has just devised its own of the mother is endangered. Medical World News, indices which separate cost Women's and civil rights October 4,1976) increases due to increased groups immediately went to services from those due to court and won a temporary price inflation. Using these, restraining order, and a final the AHA finds, "The reason decision regarding the legality hospital expenditures are of the amendment promises to After four years of contro- seemingly rising faster than take years in the federal versy, a compromise version of others is due directly to courts. the Toxic Substances Control improvement in the product— (Washington Report Act was passed and signed by hospitals care." on Medicine and Health, President Ford on October 12. October 4,1976; As originally conceived, the The Hospital Intensity In- bill required testing all chemi- dex, measuring the frequency Health LawNewsletter, October 1976) cal products for health hazards and complexity of hospital before marketing. Dropping services, indicates that inten- this provision, the Act as sity of hospital services has finally passed simply requires increased at an annual rate of that companies notify the 4.8 percent in the last six The Health Manpower Act, Environmental Protection years. This accounts for 28.5 three years in formulation, was Agency (EPA) of all new percent of hospital cost in- finally passed and signed into products at least 90 days creases between 1972 and law on October 13. This $2.1 before they are introduced 1974. billion measure continues fed- commercially. If EPA decides The Hospital Input Price eral funding to medical, osteo- the materials are potentially Index, measuring increases pathic and dental schools while dangerous, they can require due to inflation in the labor and trying to deal with geographic testing. Thus the responsibili- products the hospital must and specialty maldistribution ty to assure testing falls not on purchase, accounted for 71.5 of doctors. The program will industry but on the gov- percent of cost increases in the pay $2100 per year for each ernment, whose Environ- same period. Cost increases medical student (down from mental Protection Agency is are standardly measured by $2500), but makes several already overworked and under the Hospital Service Charge -demands on medical schools. heavy industry attack. An component of the Consumer The measure requires 35 industry displeased with Price Index, which measure percent of all residencies be in EPA's order to test a chemical increases in what patients pay. primary care specialties by can appeal the order in the Excluding increased intensity, '1978, 40 percent by 1979 and federal courts and stay the hospital cost increases paral-/ 50 percent by 1980. It also decision until the court acts, leled others in the CPI, states requires schools to accept which may take years. The the AHA. final bill is very similar to the ! Americans forced to attend (American Hospital Associa- medical schools abroad in their version originally passed by tion Press Release, third year and puts new the House, which the chemical September 21,1976) restrictions on foreign medical industry was reported earlier graduates seeking entry to the to have considered "the best US. The bill increases funding deal possible." LEGISLATION OF NOTE: of the National Health Service (New York Times, The $56.6 billion Labor- Corps (NHSC) scholarship September 7 and HEW Appropriations bill for program from $22 million now October 13,1976) 23 Cumulative Index (December 31, 1976)

Coler Hospital—Oct. '69. Columbia Medical Center—Jul. '68; Aug. '68; Nov.-Dec. '68; Abbott Laboratories—Sept.-Oct. 76* July.-Aug. '69; Sept. '69; Dec. '69; Feb. 70; Oct. 70; Dec. 70; Mar. 71. Abortion—Dec. '69; Mar. 70; Nov. 70; Dec. 70; Feb. 73; Columbia Hospital—Nov. 71. Nov.-Dec. 76. Columbus Hospital (NY)—Nov. 71; May 72; Oct. 72. Affiliations—June "68; Aug. '68; Nov.-Dec. '68; Winter '69; Committee of Internsand Residents—Aug. '68; Sept. '69. Jul.-Aug. '69; Apr. '69; Dec. 71; Sept. 73 (Montefiore-Prisons); Community Control—Oct. '68; Nov.-Dec. '69; Jan. 72; June 72. Oct. 73 (NYU-Bellevue); Jan.-Feb. 74 (Montefiore-North Community Medical School Proposal (Lincoln)—Oct. 72. Central Bronx). Community Mental Health—Aug. '68; Apr. '69; May '69. Air Pollution—Oct. 70; Nov.-Dec. 74. (Lincoln); Dec. '69; May 73; July-Aug. 75. Alford, Robert R.—May-June 76 (Review). Comprehensive Health Insurance Plan (CHIP)—Mar.-Apr. 74. American Association for Labor Legislation—Jul.-Aug. 76* Coney Island Hospital—May 72. American Assn. of Foundations for Medical Care—Feb. 73; Cook County Hospital—Apr. 73. July-Aug. 74. Cornell/New York Hospital—Sept. '69. 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; May-June 75; May-June 76. American Medical Assn.—Nov. 72; July-Aug. 74; Jan.-Feb. 75; Davis Medical School (Univ. of Calif.)—Apr. 73; May-June 75. May-June 75; July-Aug. 75; Jan.-Feb. 76*; Mar.-Apr. 76; Delafield Hospital—Nov.-Dec. '68; May 72. May-June 76*; Sept.-Oct. 76*. Diethylstilbestrol (DES)—May-June 76*. American Natl. Standards Institute—Sept. 72. Depression, The—Mar.-Apr. 76. American Nurses Assn.—Nov. 72; Sept.-Oct. 75. Downstate Medical Center—Sept. '69; Oct. 70.' Asbestos—Mar. 73; Nov.-Dec. 74; July-Aug. 76 (letter). Drug Companies—Sept.-Oct. 76. Assn. for Retarded Children—Jan. 73. Dubos, Rene—Nov.-Dec. 75. Assn. for Voluntary Sterilization—Jan.-Feb. 75; July-Aug. 75. Duke Medical School—July-Aug. 74. Association of American Medical Colleges—July-Aug. '69. Attica Prison—Nov. 71; Sept. 73 (Prison Health).

B Einstein-Montefiore—Apr. '69; Sept. '69; Sept. 70; Oct. 70; Jan. 71; Nov. 71; May 73 (Einstein); Sept. 73 (Monteflore-Prisons); Beasley, Dr. Joseph—Sept.-Oct. 75. Jan.-Feb. 74. Bellevue Hospital—Sept. 73 (Prison Ward); Oct. 73. Eisenberg, D». Leon—Nov.-Dec. 75. Beryllium Poisoning—Sept. 72. Ellwood, Dr. Paul—Jul.-Aug. 72. Beth Israel Hospital—July '68; July-Aug. '69; Sept. '69; Apr. 70; Exchange Visitor Program—Jan.-Feb. 76. Oct. 70; Jul.-Aug. 72. Beverly Enterprises—Apr. 73. Birth Control—Apr. 72; Jan.-Feb. 75; July-Aug. 75. Black Lung Disease—Sept. 71. Family Health Foundation—Sept.-Oct. 75. Blue Cross—Jul.-Aug. '69; Sept. '69; Oct. '69; Mar. 71; Jul.-Aug. Federal Health Policy—Nov. 70; Apr. 71; May 73; May-June 76. 72; Oct. 72; Sept.-Oct. 74; May-June 75; May-June 76*. Federation of Jewish Philanthropies—Apr. '69. Boston City Hospital—Jul.-Aug. 70; Oct. 73; Mar.-Apr. 74 Feldstein, Martin—May 73; Jan.-Feb. 74. (letter); May-June 74 (letter). Fiscal crisis—Mar.-Apr. 76. Boston University Medical Center—Oct. 73. Brian, Earl—Apr. 73. Brindle, James—Oct. 72. Buffalo Medical School—Nov. 71. Bureau of Occupational Safety and Health—Sept. 72. Byssinosis—Sept. 72. ERRATA

California Public Hospitals—Apr. 73; May-June 74. The three tables published in California Nursing Assn.—Sept.-Oct. 74. the September/October 1976 Carnegie Foundation—Nov. 71; May-June 75. Carter, Jimmy (Pres.)—Sept.-Oct. 76. Bulletin (Number 72) are Case Western Reserve Med. School—Jan. 70; Sept. 71. incorrectly labelled. The cor- Center for the Prevention of Violence—Sept. 73. rect titles are: "Table 1 US Certified Hospital Admission Program—Feb. 73. Charity Hospital (New Orleans)—Sept.-Oct. 75. Health Expenditures 1962-75 Cherkasky, Dr. Martin—Apr. "69; Jan.-Feb. 74. (in 000,000's)," "Table 2 go Health Movement—Apr. 71. Profit-Making Components Children's Hospital Boston,—Mar. 72. Chinese Health System—Dec. 72. of US Health Expenditures Chlorinated Hydrocarbons—May-June 76*. 1962-75 (in 000,000's)." The CIBA-Gelgy Pharmaceutical Co.—Nov.-Dec. 75. Cincinnati People's Health Movement—Sept. 71. previous title showed the City University of NY Proposal (Med. School)—Oct. 72. amounts ''in 000's." Citywide Save-Our-Homes Committee (NY)—May 72. 24 Cleveland—Sept. 71. Food and Drug Admin.—Jan.-Feb. 75; Nov.-Dec. 75; Mar.-Apr. Irvington House—Mar. 71. 76*. IWorKuen—Oct. 70. Ford, Gerald (Pres.)—Sept.-Oct. 76. Fordham Hospital—Nov.-Dec. '68; Jul.-Aug. '69. J Foreign Medical Graduates—Jan.-Feb. 76. Foucault, Michel—Nov.-Dec. 75. Jacoby, Russell—Mar.-Apr. 75. Free Clinics—Apr. 71; Oct. 71; Feb. 72; Mar.-Apr. 75. Johns-Manvllle Corp.—Mar. 73; Nov.-Dec. 74. Freud, Sigmund—Jan.-Feb. 75. 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 Ghetto Medicine Bill—Jan. 70; Apr. 70; Jul.-Aug. 72. Group Health Insurance (NY)—Oct. 72. Kalser-Permanente—Nov. 70; Nov. 73; Mar.-Apr. 74 (letter). Group Practice—Nov. 70; June 71. Key, Dr. Marcus—Sept. 72. Gouverneur Hospital—Jul. '68; July.-Aug. '69; Nov. '69; Feb. 70. King General Hospital—Apr. 73. Knickerbocker Hospital—Nov.-Dec. '68; Oct. 72. H

Haight-Ashbury Free Clinic—Oct. 71; Feb. 72. Harlem Hospital—Jul. '68; Nov.-Dec. '68; June '69; Dec. 70. Lalng, R. D.—Jan.-Feb. 75. Harlem Medical School Proposal—Oct. 72. Law, Sylvia—Sept.-Oct. 74 (Review). Harrington, Donald—Feb. 73. Lead Poisoning—Sept. '68; Apr. 70; Jan. 71. Harvard Medical School—Jan. 71; Oct. 73. Licensure—Noy. 72. HEW-Mar. 71; May 73; July-Aug. 74; Jan.-Feb. 75; July-Aug. Life Expectancy—Sept.-Oct. 76*. 75; Nov.-Dec. 75; Mar.-Apr. 76*. Lincoln Hospital—Apr. '69; Sept. 70; Oct. 70; Dec. 70; Jan. 71; Health and Hospitals Corporation—Winter '69; June '69, Sept. '69; Jan. 72; July-Aug. 72; Nov.-Dec. 76. Nov. '69; Jan. 71; Dec. 71; Feb. 72; May 72; Oct. 73; Jan.-Feb. Lincoln Community Mental Health Center—May '69; Sept. '69. 74; July-Aug. 75; Mar.-Apr. 76; Nov.-Dec. 76*. Logan, Dr. Arthur—Oct. 72. Health and Hospitals Planning Council—June '68; Winter '69; Louisiana State Univ. Medical Center—Sept.-Oct. 75. Jul.-Aug. '69; Sept. '69; Apr. 71; May 72; May 73; Mar.-Apr. Lower East Side Neighborhood Health Council-South (LESNHCS)— 76. Jul. '68; Jul.-Aug. '69; Sept. '69; Feb. 70; Apr. 70; Jul.-Aug. 70; Health Care Costs—Jan. 70; Nov. 70; June 71; May 72; Jul.-Aug. Oct. 70. 72; Jan.-Feb. 75; May-June 75; Sept.-Oct. 75; Mar.-Apr. 76*; May-June 76*; Nov.-Dec. 76*. Health Inc., Boston—Mar. 72. M Health Insurance Plan of Greater NY—Oct. 72; Dec. 72. Health Maintenance Organizations (HMO's)—Nov. 70; Apr. 71; Madera County Hospital—Apr. 73. Dec. 71; Jul.-Aug. 72; Oct. 72 (HIP); Feb. 73 (Foundations); Maimonides Community Mental Health Center—May '68. Nov. 73 (Kaiser); May-June 75. Malpractice—May-June 75; Jan.-Feb. 76; May-June 76*; Nov.- Health Planning (see Health and Hosp. Planning Council)—June Dec. 76*. '68; Winter '69; Jul.-Aug. '69; Apr. 71; May 72; May-June 75; Martin Luther King Health Center—Oct. '69. Jan.-Feb. 76; May-June 76. Maryland—Jan.-Feb. 76 (suburbs). Health Professions Educational Assistance—Nov. 71; May 73. Maternal and Child Care—May 73. Health Revolutionary Unity Movement (HRUM)—Feb. 70; Medicaid—Winter '69; June '69; Sept. '69; Jul.-Aug. 72; Oct. 72; Jul.-Aug. 70; Sept. 70; Oct. 70; Dec. 70; June 71; Jan. 72; Feb. 73 (Medi-Cal); Apr. 73 (Medl-Cal); May 73; May-June 74; Jul.-Aug. 72. Jan.-Feb. 76*; Mar.-Apr. 76*; Sept.-Oct. 76*; Nov.-Dec. 76*. Health Services Administration—Jul. '68; Sept. '68; Sept. '69; Nov. Medicaid Mills—Jul.-Aug. 72; May-June 74. Health Services Administration—Jul. '68; Sept. '68; Sept. '69; Nov. Medical Committee for Human Rights—Mar.-Apr. 75. '69; Jan. 70; May 72; Sept. 73 (Prisons). Medical Education—Nov. 71; Oct. 72; May-June 75; Mar.-Apr. Health Systems Agency (HSA)—May-June 76; July-Aug. 76*. 76*; Nov.-Dec. 76*. Health Workers—Mar. 70; July-Aug. 70; Apr. 72; Nov. 72; Medical Empires—Nov.-Dec. '68; Apr. '69; Sept. '69; Oct. 70; Apr. Sept.-Oct. 74; Jan.-Feb. 75; Sept.-Oct. 75. 73 (Calif.); Jan.-Feb. 74; Mar.-Apr. 74; July-Aug. 74; Hill-Burton—May 72; Jul.-Aug. 72; May 73; May-June 75; Sept.-Oct. 75. Nov.-Dec. 76*. Medical Industrial Complex—Nov. '69; Sept.-Oct. 76. Hilton Davis Co. (Strike)—Sept. 71. Medical Labs—Mar.-Apr. 76*. Holloman, Dr. John. L.S. (Jr.)—Mar.-Apr. 76. Medical Research—Nov.-Dec. 74; Nov.-Dec. 75. Home Health Services—Jan.-Feb. 76*; May-June, '76*. Medicare—June '69; Nov. '69; Jul.-Aug. 72; May 73; May-June Hospital Expansion—Nov. 71; Mar. 72; May 72; Mar.-Apr. 74; 75; July-Aug. 75; Jan.-Feb. 76*; Mar.-Apr. 76*. Nov.-Dec. 74; May-June 75; Jan.-Feb. 76. Mental Health—May '69; Dec. '69; May 70; June 70; July-Aug. Hospital Worker Unions—Jul.-Aug. 70; Sept. 70; June 71; Sept. 75; Nov.-Dec. 75. 71; Oct. 72; Nov. 72; Jan.-Feb. 74; Sept.-Oct. 74; Nov.-Dec. Mental Retardation—Jan. 73. 76*. Merced County Hospital—Apr. 73. Human Experimentation—Jan.-Feb. 76*; Mar.-Apr. 76*. Methadone—June 70. Methodist Hospital—Apr. 72. Metropolitan Hospital—Feb. 70. Michelson, William—Oct. 72. I Military Medicine—Apr. 70; June 71. Mitchell, Juliet—Jan.-Feb. 75 (Review). Illich, Ivan—July-Aug. 75 (Review). Montefiore Hospital—June '68; Apr. '69; Sept. '69; Oct. 70; May Industrial Health Foundation—Sept. 72; Mar. 73; Nov.-Dec. 74. 73; Jan.-Feb. 74. Industrial Medical Association—Sept. 72. Moore, Dr. Cyril—Oct. 72. Infant Formula—May-June 76*. Morrisania Hospital—Apr. '69; May 72; Jan.-Feb. 74. Institutional Licensure—Nov. 72. Mothershead, AndrewO.—Jan.-Feb. 76*. Insurance Companies—Nov. '69; Jul.-Aug. 72. Mt. Sinai Medical Center—Oct. 70; Sept.-Oct. 74. 25 N

Narcotics—June '70; Dec. 70; Jan. 72. Queens Medical School Proposal—Oct 72 National Civic Federation—July-Aug. 76.*. Quality Assurance Program (QAP)-July-Aug. 74. 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*. R National Health Insurance Program (NHIP)—May-June 74. National Health Planning and Resources Development Act (PL Regional Medical Program—July-Aug. '69; May 73. 93-641; 1974)—May-June 76; July-Aug. 76. Reich, Wilhelm—Jan.-Feb. 75. National Institute for Occupational Safety and Health—Sept. 72; Research Guide—Feb. 71. Mar. 73; Nov.-Dec. 74; Jan.-Feb. 75; July-Aug. 76. Ritalin—Nov.-Dec. 75. National Institutes of Health (NIH)—May 73. Rockefeller, Nelson—July-Aug. 75. National Medical Enterprises—Apr. 73. Rohatyn, Felix—Mar.-Apr. 76. 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. Sacramento County Hospital—Apr. 73. New York City Municipal (public) Hospitals—Mar.-Apr. 76. Sacramento Foundation for Medical Care—Feb. 73. New York City Prisons—Sept. 73. Sacramento Medical Center—Apr. 73. New York Infirmary—June 72. San Francisco Hospitals—July-Aug. 70; Mar. 71; Feb. 72; Apr. New York Medical College—May '69 (Community Mental Health 73; Sept. 73 (Prison Ward). Ctr.); Sept.'69; Oct. 70. San Joaquin Foundation for Medical Care—Feb. 73. New York State Dept. of Mental Hygiene—July-Aug. 75. Santa Cruz General Hospital—Jan.-Feb. 74. New York Times—Feb. 70; May 70. Selikoff, Dr. Irving—Sept. 72; Mar. 73; Nov.-Dec. 74. New York University Medical Center—Sept. '69; Apr. 70 (Bennett); Shell Chemical Co. (No Pest Strip)—Sept. 71; Nov.-Dec. 74 (Strike). Oct. 70; Mar. 71; June 72; Sept. 73 (Prison Ward); Oct. 73. Smith, David—Oct. 71; Feb. 72. Nixon, Richard—Nov. 70; Apr. 71; May 73; Mar.-Apr. 74; Social Workers—Sept. 70. Nov.-Dec. "T4. Soundview-Throgs Neck-Tremont Comm. Mental Health Center- North Central Bronx Hospital—May 72; Jan.-Feb. 74; Nov.-Dec. May '69. 76*. Stahl, Dr. William—Oct. 72. Nursing—Mar. 70; Sept. 71; Apr. 72; Sept. 72 (letter); Nov. 72; Sterilization—Jan.-Feb. 75; Mar.-Apr. 75 (letter); July-Aug. 75; Sept.-Oct. 74; Jan.-Feb. 75; Sept.-Oct. 75. Jan.-Feb. 76*. Nursing Homes—Nov. '69; July-Aug. 76*; Nov.-Dec. 76*. Sterling Drug Co.—Sept. 71. Student AMA—Mar. 70; Sept. 70. Student Health Organization (SHO)—Aug. '68; Mar. 70; Sept. 70; Mar.-Apr. 75. St. Joseph's Mercy Hospital (Ann Arbor)—Oct. 72. Occupational Health—Feb. 70 (GE); May 71; Sept. 71; Sept. 72; St. Vincent's Hospital—Jan. 70; Mar. 71; Jul.-Aug. 72. Mar. 73; Nov.-Dec. 74; Jan.-Feb. 75; Sept.-Oct. 75; Mar.-Apr. Swine Flu—Nov.-Dec. 76. 76*; July-Aug. 76; Nov.-Dec. 76*. Sydenham Hospital—Nov.-Dec. '68. 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 (OMB)—May 73. Oil, Chemical and Atomic Workers Union—Oct. 72; Nov.-Dec. 74; Taylor, Frederick—Sept.-Oct. 75. July-Aug. 76. Technicon Corp.—July-Aug. 74. Oil Industry—Nov.-Dec. 74. Therapeutic Communities—June 70; July-Aug. 75. Oklahoma City—Mar.-Apr. 74. Think-Lincoln—Sept. 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. Patient Dumping—May-June 74. Peace Movement—May 71. PediatricCollective—Oct. 70; Jan. 71; Jan. 72. Peer Review—Feb. 73. u Perot, H. Ross—July-Aug. 75. UCLA Medical Center—Jul.-Aug. 70; Sept. 73. Physician's Assistants—Nov. 72. United Harlem Drug Fighters—Oct. 70; Dec. 70. Physicians National Housestaff Association (PNHA)—May-June 76*. Piel Commission Report—June '68; Winter '69. Planned Parenthood—Jan.-Feb. 75; July-Aug. 75. Polyvinyl Chloride (PVC)—July-Aug. 76. Valley Medical Center—Apr. 73. Prepaid Health Plans (PHP's)—Feb. 73; Apr. 73. Vanderbilt Clinic—May 70. Prisons—May 70; Nov. 71; Sept. 73. Veterans Administration Hospitals—Apr. 70; May 71. Professional Standards Review Organizations (PSRO's)—Feb. 73; Virchow, Dr. Rudolph—Nov.-Dec. 75. July-Aug. 74. Profits in Health—Sept.-Oct. 76. Psychiatry—May '69; May 70; Jan.-Feb. 75; July-Aug. 75; w Nov.-Dec. 75. Public Health Hospitals—Mar. 71. Walsh-Healy Act—Sept. 72. 26 Public Hospitals—April 73; May-June 74; Mar.-Apr. 76. Washington Heights-lnwood Community Mental Health Center- Nov.-Dec. '68; Apr. '69; Dec. '69. Young Lords—Oct. '69; Feb. 70; Sept. 70; Oct. 70; Dec. 70; Washington, D.C.— Jan.-Feb. 76 (suburbs). Jan. 72. Weinberger, Caspar—May 73. Welby, Marcus—May-June 74 (Review). Wender, Dr. Paul—Nov.-Dec. 75. Wesley Hospital (Chicago)—Jul.-Aug. 70. Wi I lowbrook State School—Jan. 73. Women's Health—Mar. 70; Apr. 72; Dec. 72; Jan.-Feb. 75; July-Aug. 75. Workers' Compensation—July-Aug. 76. HEALTH/PAC BULLETIN BACK ISSUES 1-9 copies, $1.25 each; 10 or more copies, $1.00 each. For orders of $10 or less, add 20% Yolo General Hospital—Apr. 73. for postage; for orders over $10, add 10%.

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