formance in their profession. See David M. Rubin and Val Hendy, "Swine Influenza and the News Media," Annals of Internal Medicine, Vol.87, pp. 769-774, 1977.

  

38. For that matter, why stop with Federal programs? Deciding proper boundaries for a competition raises issues about Federal-state and public-private roles. This is one reason why such boundaries don't get set. Consider, for example, pneumococcal pneumonia, a frequent cause of death for aged persons and for others at high risk, including persons—many of them children—whose spleens have been removed after an accident. A newly marketed vaccine reliably prevents infection from the 14 common subtypes of the pneumococcus. These account for 80 percent of this pneumonia. The preventive is apparently both safe and lasting. It could prolong thousands of lives each year. The disease is not highly communicable, but it is far more serious for most of those who get it than is influenza. Does this argue for a Federal initiative? If so, at the expense of the flu program? We pose these questions not to answer them but to suggest the range of readily conceivable budgetary trade-offs. As this shows, however, a competitive arena is not easily established. In the case of influenza, none yet exists.

  

39. Sir Charles H. Stuart-Harris and Geoffrey C. Schild, Influenza: The Viruses and the Disease, Publishing Sciences Group, Inc., Littleton, MA, 1976,pp. 96-111.

  

40. Chien Liu, "Influenza." Ch. 27 in Paul C. Hoeprich (editor) Infectious Diseases, Harper and Row, 1977, pp. 271-276.

  

41. J. Housworth and A. D. Langmuir, Excess mortality from epidemic influenza, 1957-1966, American Journal of Epidemiology, Vol. 100, pp. 40-48, 1974. See also S. D. Collins, "Excess Deaths from Pneumonia and Influenza and from Important Chronic Diseases During Epidemics, 1918-1951," United States Public Health Service, Public Health Monograph No. 10, U.S. Government Printing Office, Washington, D.C. 1952, pp. 6-7.

  

42. Robert E. Serfling, "Methods for Current Statistical Analysis of Excess Pneumonia-Influenza Deaths," Public Health Reports, Vol. 78, No. 6, June, 1963, pp. 494-506.

  

43. T. C. Eickhoff, I. L. Sherman and R. E. Serfling, "Observations on excess mortality associated with epidemic influenza," Journal of the American Medical Association, Vol. 176, pp. 776-782, 1961.

  

44. Albert B. Sabin, "Mortality from Pneumonia and Risk Conditions During Influenza Epidemics: high influenza morbidity during non-pandemic years," Journal of the American Medical Association, Vol. 237, pp. 2823-2828, 1977. Epidemiologists from CDC published a response to Sabin's article criticizing his methodology, but acknowledging that CDC excess mortality estimates are likely to differ from those based on NCHS mortality data for the entire country. See Michael B. Gregg, Dennis J. Bregman, Richard J. O'Brien, J. Donald Millar, "Influenza Related Mortality," Journal of the American Medical Association, Vol. 239, pp. 115-116, 1978.

  

45. See, for example, Marc Lalonde, Hospital Morbidity and Total Mortality in Canada, Canadian Department of Health and Welfare, Long-range Planning Branch, Health Programs Branch, Ottawa, Ontario, October, 1973.

  

46. These are published as a series by the National Center for Health Statistics. See, for



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