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Letters I to the Editor
1
Further Thoughts on Swine Flu Immunization We read, with considerable interest, the editorial by Dr. Stephen Schoenbaum in the March issue' in which he discussed factors related to the success, or lack of success, of the National Influenza Immunization Program for swine flu. Though a number of significant points were made, and an analysis of certain hypotheses was undertaken, we believe other points of significance were omitted, and at least one additional hypothesis was overlooked. It became evident within several weeks after the initial report of the incident at Fort Dix, New Jersey that this might be an isolated situation and not the beginning of a major epidemic. Although combined virus isolation and serologic testing indicated the possible involvement of several hundred recruits with the A/New Jersey strain, the A/Victoria virus which was spreading simultaneously in the same population was infecting much larger numbers of troops.2 In the meantime, circumstances surrounding the one death which had been reported cast doubt on its anecdotal significance. In July 1976, Beare and Craig3 reported a study of the inoculation of the A/New Jersey strain into human volunteers with a clear demonstration that the virulence was intermediate between human and animal strains. They concluded that the Fort Dix experience was probably an isolated event. In the meantime, the Advisory Group on Influenza of the Joint Committee on Vaccination and Immunization in Great Britain concluded that the outbreak was localized and not unusually severe.4 The Group felt that an epidemic was by no means certain and advised against mass immunization in Great Britain. 820
This brings us to an hypothesis to explain the varied immunization levels achieved which was overlooked by Dr. Schoenbaum. This has to do with the beliefs and influence of local health officials. Many of the health officers of our larger cities and more densely populated counties are either Board Certified in Public Health or have the MPH degree. We suggest that many of these individuals, like ourselves, were not convinced by the epidemiological evidence that a serious swine flu epidemic was likely in 1976 and, therefore, seriously questioned the advisability of diverting the personnel and financial resources required for a massive immunization from other important health problems. We further feared that problems with a hasty immunization program might well be counter-productive to population acceptance of more important vaccines. The views of the local health officer have a significant effect on the beliefs of residents in his or her community. If the health official is not convinced of the value of a program, it is unlikely to be implemented even though strongly urged by State officials. Christopher M. G. Buttery, MD, MPH Associate Professor of Community Medicine Department ofFamily Medicine and Donald J. Merchant, PhD Professor and Chairman Microbiology and Immunology Eastern Virginia Medical School P.O. Box 1980 Norfolk, VA 23501 REFERENCES
1. Schoenbaum, SC, Influenza vaccine-unacceptable or unaccepted, Am J Public Health 69:219-221, 1979. 2. Current Trends, Influenza, Morbidity and Mortality Weekly Report 27:63, 1976
3. Beare, AS and Craig, JW, Virulence for man of a human influenza-A virus antigenically similar to "classical" swine viruses, The Lancet 2:4 (July 3) 1976. 4. Notes and News, Swine Influenza, The Lancet 1:921, 1976.
Comments on Skin Color and Blood Pressure among Blacks I find it surprising that Harburg, et al., interpret their recent findings on blood pressure and skin color among Blacks as evidence that "varied gene mixtures may be related to blood pressure."'I Without direct measurement of gene frequency or closely linked markers, genetic mechanisms are a "diagnosis by exclusion." In fact, other explanations are not wholly excluded as the accompanying editorial points out.2 Since class, skin color and blood pressure among Blacks are all related, demonstrating an independent effect of skin color requires adequate control for social class. What evidence do the authors have that education and income adequately measure the life-long effect of class and race discrimination? Given the same level of formal education, Blacks are segregated to inferior schools. With the same income, Blacks live in worse neighborhoods. The same gradient would be expected to apply from light to dark among Blacks, and Harburg, et al., show a significant relationship between education and skin color among males. The findings in South Carolina were even more striking.3 State authority, for example, the police, react to skin color independent of income and education. A whole range of dietary practices, like salt intake, could be correlated with skin color, and might play a role. The person taking the blood pressure measurement also made the estimate of skin color and perhaps had a preconceived notion AJPH August 1979, Vol. 69, No. 8
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Letters I to the Editor
1
Further Thoughts on Swine Flu Immunization We read, with considerable interest, the editorial by Dr. Stephen Schoenbaum in the March issue' in which he discussed factors related to the success, or lack of success, of the National Influenza Immunization Program for swine flu. Though a number of significant points were made, and an analysis of certain hypotheses was undertaken, we believe other points of significance were omitted, and at least one additional hypothesis was overlooked. It became evident within several weeks after the initial report of the incident at Fort Dix, New Jersey that this might be an isolated situation and not the beginning of a major epidemic. Although combined virus isolation and serologic testing indicated the possible involvement of several hundred recruits with the A/New Jersey strain, the A/Victoria virus which was spreading simultaneously in the same population was infecting much larger numbers of troops.2 In the meantime, circumstances surrounding the one death which had been reported cast doubt on its anecdotal significance. In July 1976, Beare and Craig3 reported a study of the inoculation of the A/New Jersey strain into human volunteers with a clear demonstration that the virulence was intermediate between human and animal strains. They concluded that the Fort Dix experience was probably an isolated event. In the meantime, the Advisory Group on Influenza of the Joint Committee on Vaccination and Immunization in Great Britain concluded that the outbreak was localized and not unusually severe.4 The Group felt that an epidemic was by no means certain and advised against mass immunization in Great Britain. 820
This brings us to an hypothesis to explain the varied immunization levels achieved which was overlooked by Dr. Schoenbaum. This has to do with the beliefs and influence of local health officials. Many of the health officers of our larger cities and more densely populated counties are either Board Certified in Public Health or have the MPH degree. We suggest that many of these individuals, like ourselves, were not convinced by the epidemiological evidence that a serious swine flu epidemic was likely in 1976 and, therefore, seriously questioned the advisability of diverting the personnel and financial resources required for a massive immunization from other important health problems. We further feared that problems with a hasty immunization program might well be counter-productive to population acceptance of more important vaccines. The views of the local health officer have a significant effect on the beliefs of residents in his or her community. If the health official is not convinced of the value of a program, it is unlikely to be implemented even though strongly urged by State officials. Christopher M. G. Buttery, MD, MPH Associate Professor of Community Medicine Department ofFamily Medicine and Donald J. Merchant, PhD Professor and Chairman Microbiology and Immunology Eastern Virginia Medical School P.O. Box 1980 Norfolk, VA 23501 REFERENCES
1. Schoenbaum, SC, Influenza vaccine-unacceptable or unaccepted, Am J Public Health 69:219-221, 1979. 2. Current Trends, Influenza, Morbidity and Mortality Weekly Report 27:63, 1976
3. Beare, AS and Craig, JW, Virulence for man of a human influenza-A virus antigenically similar to "classical" swine viruses, The Lancet 2:4 (July 3) 1976. 4. Notes and News, Swine Influenza, The Lancet 1:921, 1976.
Comments on Skin Color and Blood Pressure among Blacks I find it surprising that Harburg, et al., interpret their recent findings on blood pressure and skin color among Blacks as evidence that "varied gene mixtures may be related to blood pressure."'I Without direct measurement of gene frequency or closely linked markers, genetic mechanisms are a "diagnosis by exclusion." In fact, other explanations are not wholly excluded as the accompanying editorial points out.2 Since class, skin color and blood pressure among Blacks are all related, demonstrating an independent effect of skin color requires adequate control for social class. What evidence do the authors have that education and income adequately measure the life-long effect of class and race discrimination? Given the same level of formal education, Blacks are segregated to inferior schools. With the same income, Blacks live in worse neighborhoods. The same gradient would be expected to apply from light to dark among Blacks, and Harburg, et al., show a significant relationship between education and skin color among males. The findings in South Carolina were even more striking.3 State authority, for example, the police, react to skin color independent of income and education. A whole range of dietary practices, like salt intake, could be correlated with skin color, and might play a role. The person taking the blood pressure measurement also made the estimate of skin color and perhaps had a preconceived notion AJPH August 1979, Vol. 69, No. 8
