EDITORIALS
strategy could achieve better protection against both diseases, and the cost to deliver these vaccines would be de-
creased substantially.
6.
7.
SAUL KRUGMAN, MD Address reprint requests to Dr. Saul Krugman, Professor, Department of Pediatrics, New York University, School of Medicine, 550 First Avenue, New York, NY 10016.
8. 9.
RE-EAENCES 1. Krugman S: Present status of measles and rubella immunization in the United States: A medical progress report. J Ped 90:1-12, 1977. 2. HTerrmann KL, Halstead SB, Brandling-Bennett AD, et al: Rubella immunization. Persistence of antibody 4 years after a large-scale field trial. JAMA 235:2201-2204, 1976. 3. Modlin JF, Herrmann KL, Brandling-Bennett AD, et al: congenial anomaly after inadvertent rubella vaccination of pregnant women. N Eng J Med 294:972-974, 1976. 4. Povar GJ, Maloney M, Watson WN, et al: Rubella screening and follow-up immunization in Vermont. Am J Public Health 69:285-286, 1979. 5. Chappell JA and Taylor MAH: Implications of rubella susceptibility in young adults. Am J Public Health 69:279-281, 1979.
10. 11.
12.
13. 14.
Paivo CE, Weiss KS, and Liss SM: A rubella screening and inihnunization program in an adolescent clinic. Am J Public Health 69:283-285, 1979. Weiss KE, Falvo CE, Buimovici-Klein E, et al: Evaluation of an employee health service as a setting for a rubella screening and immunization progratn. Am J Public Health 69:281-283, 1979. McLaughlin MC and Gold LH: The New York rubella incident: A case for changing hospital policy regarding rubella testink and immunization. Am J Public Health 69:287-289, 1979. Rubella and Congenital Rubella, U.S. 1977-1978. MMWR, 27:495-497 (Dec. 8) 1978. Center for Disease Control: Exposure of Patients to Rubella by Medical Personnel-California. MMWR 27:123 (April 14), 1978. Immunization: Benefit vs Risk Factors. Symposium of the Internal Association of Biological Standardization, Nov. 15-17, 1978, Brussels, Belgium (to be published). Anthony N, Reed M, Leff AM, et al: Immunization: Public health programming through law enforcement. Am J Public Health 67:763-764, 1977. Measles and School Immunization Requirements-United States, 1978. MMWR 27:303-304 (Aug. 18) 1978. Rubella Vaccine. Recommendation of the U.S. Public Health Service Advisory Committee on Immunization Practices. MMWR 27:451 (Nov. 17) 1978.
Influenza Vaccine- Unacceptable or Unaccepted The Natinhal Influenza Immunization Program for swine flu is an increasingly useful example for illustrating the features and problems of immunization programs in general. When the program was first announced by President Gerald Ford in March 1976, the intent was to produce "sufficient vaccine to inoculate every man, woman, and child in the United States." Ultimately less than 150 million doses were produced add only 43 million consumed. Optimists cite the fact that more people were immunized in the two and one-half months from inception of the program until its termination than in any other similar period of time. Is it not of greater importance, however, that only about 40 per cent of persons considered at high-risk for complications and death from influenza participated in the swine flu program and that less than 25 per cent of the remaining adult population participated? The response in the high-risk group is particularly disappointing when one recalls that official recommendations for the past two decades have called for annual immunization of this group. Monto and Ross in an article in this issue of the Journal report on the swine flu program in Tecumseh, Michigan and AJPH March, 1979, Vol. 69, No. 3
surrounding Lenawee County and record that 65 per cent in the city and 57 per cent in the county participated.' They attribute these relatively high rates to the "very vigorous and well organized program of the county health department." Are the rates in this county high enough for a location with a vigorous, well-organized program? Is this about the best one can do with a voluntary program? On the other hand, these rates are indisputably higher than those in many other locations. What are the specifics of vigor and organization that might lead to greater participation in Tecumseh than elsewhere? Which approaches are most effective and which are most cost-effective? It seems likely that several factors did affect participation in the swine flu program. First, vaccine was not available at all until October 1, 1976; and this starting date was selected after several postponements. Groups trying on state and local levels to plan immunization activities through the preceding summer did not have a precise date for vaccine availability or a distribution schedule. Even when the program started, vaccine was not always available in adequate amounts for scheduled clinics. According to Monto and 219
EDITORIALS
Ross, Lenawee County was among the first in Michigan to initiate the program and was apparehtly allocated sufficient vaccine to meet demand without day-to-day shortages. Secondly, the deaths of three elderly persons vaccinated within a one-hour period on October 11 that year at a single clinic in Pittsburgh (Allegheny County), PA received national publicity. Whether these deaths were "coincidental" or related in some non-chance way to the program was controversial.2 There is no evidence that they were related directly to the vaccine; and this information was also quickly disseminated. Nonetheless, enthusiasm for getting vaccinated was dampened, perhaps even in Lenawee Couinty. It is interesting that in Tecumseh the elderly did not participate at a greater rate than younger persons, even though the elderly are in the high-risk group. Is this because all groups participated so well? Or, were the elderly turned off by some aspect of the program such as the Allegheny County deaths? In November 1976, a case of swine flu was reported from Missouri. Although this mlight have stimulated participation in the program it quickly became evident that no secondary cases were occurring. This may have increased public perception that swine flu was not ap imminent threat and that there was no need to ruish in for immunization. Then, in early December, a possible association of swine flu immunization and Guillain Barre Syndrome was suggested and quickly confirmed by a special survey. This led to a moratorium on December 16 which became the virtual termination of the program. Sbme have argued that the program participation rates would have been substantially greater had this premature termination hot occurred. Although possibly true, it is regrettable, since an effective influenza immunization program should be completed before the influenza season. Accordingly the swine flu program ideally should have been completed by niid-December. In May 1976, Barbara McNeil, Joel Kavet, and I undertook an analysis of the swine influenza decision.3 This analysis included a poll of experts in the areas of influenza and immunization. Central to our calculations of the net benefits of various immunization strategies which might have been chosen was the rate of acceptance or participation in the projected program. The experts estimated that over 60 per cent of the general population would accept vaccine in the swine flu program. Using the assumptions provided by the experts and incorporated into the benefit-cost model, it would have required at least 60 per cent participation nationwide to make a program for the general population appear preferable economically to one limited io Ihe high-risk group. Meager information available at that time indicated that 33 per cent was a more realistic rate; and the swine flu program eventually bore this out. Acceptance of vaccine by individuals might follow the assumptions of the Health Belief Model; i.e., persons who think the disease is an important threat to them and that the vaccine is a safe and effective means of prevention would be the most likely to accept it. Intuitively this makes sense; and it appears that major reasons stated by individuals for not getting immunized in the swine flu program include the feeling that the vaccine was not necessary and the fear of adverse reactions.4 5 Unquestionably some of this sentiment 220
AL DC i FL
ID IL KS MD ME DE MS Hi NB
AZ CA GA
NC NJ NV Ml IN NY NH MT AK LA OK OH NM co
|CT
SC IORIPAIRI '.
TNIVTJ IA IMOI
AR MA IWV I m +INYC1WA i i
0
10
20
MNINDI
VA Ii WI
30
40
Percent
i 50
VT
I
I
I
SD IWYIi
-1
60
70
80
90
100
Participation
FIGURE 1-National Influenza Immunization Program Participation Rates by State for Persons Age 18 and Over, 1976.*
reflects lack of education6 or possibly active advice from physicians, who themselves are not enthusiastic about influenza immunization. Patterns of acceptance of vaccine in the swine flu program are intriguing. The accompanying figure shows that participation by state varied from less than 10 per cent to over 70 per cent. There were marked differences within regions: participation rates in Connecticut were three times those of Massachusetts. The differences in participation rates from state to state or even within states are so large that it is unlikely that differences in individual attitudes explain them. Rather, organizational factors within states must have played an important role. Access to vaccination was undoubtedly much greater in some areas than others. We will lose an important lesson to be gleaned from the swine flu progranr if we do not try to ascertain formally which factors motivate state and local program planning and execution. 1 believe that the swine flu program was not a fiasco in North Dakota, Puerto Rico, or Wyoming. It was a fiasco nationally to the extent that there was such poor participation in most areas. As persons interested in public health who presumably believe immunization has something to offer, can we be satisfied with 30 per cent or even 60 per cent participation rates in any influenza immunization program? If not, how are we going to improve participation even in the "best organized" areas? Recently, in the area of childhood immunization it has been fashionable to fall back on enforcement of immuniza*SOURCE: Center for Disease Control, National Influenza Immunization Program: Unpublished information; revised through
February 2, 1977.
AJPH March, 1979, Vol. 69, No. 3
EDITORIALS
tion laws. Although this may be an effective strategy, it is a sigp of our inability to develop effective voluntary programs and can be argued to infringe upon civil liberties. In the absence of a disease eradication program is it to society's advantage to compel immunization by not allowing children to enter school or return to school? Would it have been to society's advantage to have had a compulsory swine flu program in which the right to vote or have a driver's license was suspended untij proof of immunization was presented? Since it is likely that influenza immunization is going to remain voluntary we are going to have to explore further the factors leading people to accept or reject it; and we are going to have to explore strategies for increasing acceptance. Developing less reactogenic vaccines, redefining the high-risk group into categories of relative risk so that programs can focus first on the highest risk individuals, and exploring the use of incentives may all have a role. One thing is certain-if we continue to settle for current rates of participation in influenza vaccine programs we don't really believe in the value of influenza immunization.
STEPHEN C. SCHOENBAUM, MD
Address reprint requests to Dr. Stephen C. Schoenbaum, Department of Medicine, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, MA 02115. Dr. Schoenbaum is also affiliated with the Harvard School of Public Health, and is Director of Medical Services at Boston Hospital for Women.
REFERENCES 1. Monto AS and Ross HW: Swine influenza vaccine program in the community: Acceptability, reactions and responses. Am J Public Health 69:233-237, 1979. 2. Boffey PM: Swine flu: were the three deaths in Pittsburgh a coincidence? Science 194:590-591, 648, 1976. 3. Schoenbaum SC, McNeil BJ, Kavet J: The swine-influenza decision. N EngI J Med 295:759-765, 1976. 4. Center for Disease Control, Bureau of Health Education: National survey of public attitudes towards A/New Jersey/76 influenza vaccination: report no. 4. Atlanta, GA. November 30, 1976. 5. Aho WR: Participation of Providence senior citizens in the swine flu inoculation program. RI Med J 60:525-530, 1977. 6. Ennis FA, Tully M, Barry DW, Gordon E: Acceptance of vaccination by the elderly. In P. Selby, ed., Influenza: Virus, Vaccines, and Strategy (Proceedings of a working group on pandemic influenza, Rougemont, January 26-28, 1976). London and New York, Academic Press, 1976.
The Use of Health Surveys in Health Systems Agency Planning At a time when allocation of limited health resources is a major public issue, new or additional insights into the collection of relevant data for health planning are most welcome. Siemiatycki, in a report published in this issue of the Journal,' confirms some previous reports on the comparative effectiveness and costs of various combinations of mail, telephone, and face-to-face interviews in the conduct of community surveys. Of particular interest is the finding that the use of the telephone in such surveys if followed up by household interviews can lead to a high response at a comparatively low cost. Household health surveys-whether local community or multi-county in coverage-can provide useful information for health planning. Survey information can be used to complement data from other sources. Demographic, small-area data are available from the latest Census of Population and Housing printed reports or summary tapes, in which the basic aggregate unit is the enumeration district or the block group with average coverage of about 250 households (but also with great variation).2 Service information is usually available from health agencies, e.g., the number of recipients of a particular health service; resource information would include the amount of money expended on a particular service. These other types of information primarily yield input measures of health services; often, it falls upon the household survey to produce output measures of the effects of varAJPH March, 1979, Vol. 69, No. 3
ious health care strategies on the total community and the relevant health target groups. Furthermore, surveys can be structured to assess the total health and social needs of individuals and families whereas other types of information reflect program data, which, of necessity, are fragments of the whole. The United States, in implementing the National Health Planning and Resources Development Act (PL 93-641), is committed to a policy of health planning at the national, state, and area-wide levels. Although health planning of this kind is a political activity (using the broadest definition of "'political"), it is essential that we apply usable and valid data to allocate resources if we are to promote the goals of improving access to high quality health care at reasonable cost, as projected by the law. The report by Siemiatycki' has implications for those who have responsibility for implementing the Act. One of the pitfalls in planning as performed at the Health Systems Agency (HSA) level is that there may be great variations in the needs for or utilization of health services within a health service area.3 These variations can be taken into account in health planning only if the data currently available through surveys by the National Center for Health Statistics and other federal health programs, including the Cooperative Health Statistics System conducted at the state level, are supplemented by small area surveys. However, Section 1513 (b) of PL 93-641 enjoins the Health 221
strategy could achieve better protection against both diseases, and the cost to deliver these vaccines would be de-
creased substantially.
6.
7.
SAUL KRUGMAN, MD Address reprint requests to Dr. Saul Krugman, Professor, Department of Pediatrics, New York University, School of Medicine, 550 First Avenue, New York, NY 10016.
8. 9.
RE-EAENCES 1. Krugman S: Present status of measles and rubella immunization in the United States: A medical progress report. J Ped 90:1-12, 1977. 2. HTerrmann KL, Halstead SB, Brandling-Bennett AD, et al: Rubella immunization. Persistence of antibody 4 years after a large-scale field trial. JAMA 235:2201-2204, 1976. 3. Modlin JF, Herrmann KL, Brandling-Bennett AD, et al: congenial anomaly after inadvertent rubella vaccination of pregnant women. N Eng J Med 294:972-974, 1976. 4. Povar GJ, Maloney M, Watson WN, et al: Rubella screening and follow-up immunization in Vermont. Am J Public Health 69:285-286, 1979. 5. Chappell JA and Taylor MAH: Implications of rubella susceptibility in young adults. Am J Public Health 69:279-281, 1979.
10. 11.
12.
13. 14.
Paivo CE, Weiss KS, and Liss SM: A rubella screening and inihnunization program in an adolescent clinic. Am J Public Health 69:283-285, 1979. Weiss KE, Falvo CE, Buimovici-Klein E, et al: Evaluation of an employee health service as a setting for a rubella screening and immunization progratn. Am J Public Health 69:281-283, 1979. McLaughlin MC and Gold LH: The New York rubella incident: A case for changing hospital policy regarding rubella testink and immunization. Am J Public Health 69:287-289, 1979. Rubella and Congenital Rubella, U.S. 1977-1978. MMWR, 27:495-497 (Dec. 8) 1978. Center for Disease Control: Exposure of Patients to Rubella by Medical Personnel-California. MMWR 27:123 (April 14), 1978. Immunization: Benefit vs Risk Factors. Symposium of the Internal Association of Biological Standardization, Nov. 15-17, 1978, Brussels, Belgium (to be published). Anthony N, Reed M, Leff AM, et al: Immunization: Public health programming through law enforcement. Am J Public Health 67:763-764, 1977. Measles and School Immunization Requirements-United States, 1978. MMWR 27:303-304 (Aug. 18) 1978. Rubella Vaccine. Recommendation of the U.S. Public Health Service Advisory Committee on Immunization Practices. MMWR 27:451 (Nov. 17) 1978.
Influenza Vaccine- Unacceptable or Unaccepted The Natinhal Influenza Immunization Program for swine flu is an increasingly useful example for illustrating the features and problems of immunization programs in general. When the program was first announced by President Gerald Ford in March 1976, the intent was to produce "sufficient vaccine to inoculate every man, woman, and child in the United States." Ultimately less than 150 million doses were produced add only 43 million consumed. Optimists cite the fact that more people were immunized in the two and one-half months from inception of the program until its termination than in any other similar period of time. Is it not of greater importance, however, that only about 40 per cent of persons considered at high-risk for complications and death from influenza participated in the swine flu program and that less than 25 per cent of the remaining adult population participated? The response in the high-risk group is particularly disappointing when one recalls that official recommendations for the past two decades have called for annual immunization of this group. Monto and Ross in an article in this issue of the Journal report on the swine flu program in Tecumseh, Michigan and AJPH March, 1979, Vol. 69, No. 3
surrounding Lenawee County and record that 65 per cent in the city and 57 per cent in the county participated.' They attribute these relatively high rates to the "very vigorous and well organized program of the county health department." Are the rates in this county high enough for a location with a vigorous, well-organized program? Is this about the best one can do with a voluntary program? On the other hand, these rates are indisputably higher than those in many other locations. What are the specifics of vigor and organization that might lead to greater participation in Tecumseh than elsewhere? Which approaches are most effective and which are most cost-effective? It seems likely that several factors did affect participation in the swine flu program. First, vaccine was not available at all until October 1, 1976; and this starting date was selected after several postponements. Groups trying on state and local levels to plan immunization activities through the preceding summer did not have a precise date for vaccine availability or a distribution schedule. Even when the program started, vaccine was not always available in adequate amounts for scheduled clinics. According to Monto and 219
EDITORIALS
Ross, Lenawee County was among the first in Michigan to initiate the program and was apparehtly allocated sufficient vaccine to meet demand without day-to-day shortages. Secondly, the deaths of three elderly persons vaccinated within a one-hour period on October 11 that year at a single clinic in Pittsburgh (Allegheny County), PA received national publicity. Whether these deaths were "coincidental" or related in some non-chance way to the program was controversial.2 There is no evidence that they were related directly to the vaccine; and this information was also quickly disseminated. Nonetheless, enthusiasm for getting vaccinated was dampened, perhaps even in Lenawee Couinty. It is interesting that in Tecumseh the elderly did not participate at a greater rate than younger persons, even though the elderly are in the high-risk group. Is this because all groups participated so well? Or, were the elderly turned off by some aspect of the program such as the Allegheny County deaths? In November 1976, a case of swine flu was reported from Missouri. Although this mlight have stimulated participation in the program it quickly became evident that no secondary cases were occurring. This may have increased public perception that swine flu was not ap imminent threat and that there was no need to ruish in for immunization. Then, in early December, a possible association of swine flu immunization and Guillain Barre Syndrome was suggested and quickly confirmed by a special survey. This led to a moratorium on December 16 which became the virtual termination of the program. Sbme have argued that the program participation rates would have been substantially greater had this premature termination hot occurred. Although possibly true, it is regrettable, since an effective influenza immunization program should be completed before the influenza season. Accordingly the swine flu program ideally should have been completed by niid-December. In May 1976, Barbara McNeil, Joel Kavet, and I undertook an analysis of the swine influenza decision.3 This analysis included a poll of experts in the areas of influenza and immunization. Central to our calculations of the net benefits of various immunization strategies which might have been chosen was the rate of acceptance or participation in the projected program. The experts estimated that over 60 per cent of the general population would accept vaccine in the swine flu program. Using the assumptions provided by the experts and incorporated into the benefit-cost model, it would have required at least 60 per cent participation nationwide to make a program for the general population appear preferable economically to one limited io Ihe high-risk group. Meager information available at that time indicated that 33 per cent was a more realistic rate; and the swine flu program eventually bore this out. Acceptance of vaccine by individuals might follow the assumptions of the Health Belief Model; i.e., persons who think the disease is an important threat to them and that the vaccine is a safe and effective means of prevention would be the most likely to accept it. Intuitively this makes sense; and it appears that major reasons stated by individuals for not getting immunized in the swine flu program include the feeling that the vaccine was not necessary and the fear of adverse reactions.4 5 Unquestionably some of this sentiment 220
AL DC i FL
ID IL KS MD ME DE MS Hi NB
AZ CA GA
NC NJ NV Ml IN NY NH MT AK LA OK OH NM co
|CT
SC IORIPAIRI '.
TNIVTJ IA IMOI
AR MA IWV I m +INYC1WA i i
0
10
20
MNINDI
VA Ii WI
30
40
Percent
i 50
VT
I
I
I
SD IWYIi
-1
60
70
80
90
100
Participation
FIGURE 1-National Influenza Immunization Program Participation Rates by State for Persons Age 18 and Over, 1976.*
reflects lack of education6 or possibly active advice from physicians, who themselves are not enthusiastic about influenza immunization. Patterns of acceptance of vaccine in the swine flu program are intriguing. The accompanying figure shows that participation by state varied from less than 10 per cent to over 70 per cent. There were marked differences within regions: participation rates in Connecticut were three times those of Massachusetts. The differences in participation rates from state to state or even within states are so large that it is unlikely that differences in individual attitudes explain them. Rather, organizational factors within states must have played an important role. Access to vaccination was undoubtedly much greater in some areas than others. We will lose an important lesson to be gleaned from the swine flu progranr if we do not try to ascertain formally which factors motivate state and local program planning and execution. 1 believe that the swine flu program was not a fiasco in North Dakota, Puerto Rico, or Wyoming. It was a fiasco nationally to the extent that there was such poor participation in most areas. As persons interested in public health who presumably believe immunization has something to offer, can we be satisfied with 30 per cent or even 60 per cent participation rates in any influenza immunization program? If not, how are we going to improve participation even in the "best organized" areas? Recently, in the area of childhood immunization it has been fashionable to fall back on enforcement of immuniza*SOURCE: Center for Disease Control, National Influenza Immunization Program: Unpublished information; revised through
February 2, 1977.
AJPH March, 1979, Vol. 69, No. 3
EDITORIALS
tion laws. Although this may be an effective strategy, it is a sigp of our inability to develop effective voluntary programs and can be argued to infringe upon civil liberties. In the absence of a disease eradication program is it to society's advantage to compel immunization by not allowing children to enter school or return to school? Would it have been to society's advantage to have had a compulsory swine flu program in which the right to vote or have a driver's license was suspended untij proof of immunization was presented? Since it is likely that influenza immunization is going to remain voluntary we are going to have to explore further the factors leading people to accept or reject it; and we are going to have to explore strategies for increasing acceptance. Developing less reactogenic vaccines, redefining the high-risk group into categories of relative risk so that programs can focus first on the highest risk individuals, and exploring the use of incentives may all have a role. One thing is certain-if we continue to settle for current rates of participation in influenza vaccine programs we don't really believe in the value of influenza immunization.
STEPHEN C. SCHOENBAUM, MD
Address reprint requests to Dr. Stephen C. Schoenbaum, Department of Medicine, Peter Bent Brigham Hospital, 721 Huntington Avenue, Boston, MA 02115. Dr. Schoenbaum is also affiliated with the Harvard School of Public Health, and is Director of Medical Services at Boston Hospital for Women.
REFERENCES 1. Monto AS and Ross HW: Swine influenza vaccine program in the community: Acceptability, reactions and responses. Am J Public Health 69:233-237, 1979. 2. Boffey PM: Swine flu: were the three deaths in Pittsburgh a coincidence? Science 194:590-591, 648, 1976. 3. Schoenbaum SC, McNeil BJ, Kavet J: The swine-influenza decision. N EngI J Med 295:759-765, 1976. 4. Center for Disease Control, Bureau of Health Education: National survey of public attitudes towards A/New Jersey/76 influenza vaccination: report no. 4. Atlanta, GA. November 30, 1976. 5. Aho WR: Participation of Providence senior citizens in the swine flu inoculation program. RI Med J 60:525-530, 1977. 6. Ennis FA, Tully M, Barry DW, Gordon E: Acceptance of vaccination by the elderly. In P. Selby, ed., Influenza: Virus, Vaccines, and Strategy (Proceedings of a working group on pandemic influenza, Rougemont, January 26-28, 1976). London and New York, Academic Press, 1976.
The Use of Health Surveys in Health Systems Agency Planning At a time when allocation of limited health resources is a major public issue, new or additional insights into the collection of relevant data for health planning are most welcome. Siemiatycki, in a report published in this issue of the Journal,' confirms some previous reports on the comparative effectiveness and costs of various combinations of mail, telephone, and face-to-face interviews in the conduct of community surveys. Of particular interest is the finding that the use of the telephone in such surveys if followed up by household interviews can lead to a high response at a comparatively low cost. Household health surveys-whether local community or multi-county in coverage-can provide useful information for health planning. Survey information can be used to complement data from other sources. Demographic, small-area data are available from the latest Census of Population and Housing printed reports or summary tapes, in which the basic aggregate unit is the enumeration district or the block group with average coverage of about 250 households (but also with great variation).2 Service information is usually available from health agencies, e.g., the number of recipients of a particular health service; resource information would include the amount of money expended on a particular service. These other types of information primarily yield input measures of health services; often, it falls upon the household survey to produce output measures of the effects of varAJPH March, 1979, Vol. 69, No. 3
ious health care strategies on the total community and the relevant health target groups. Furthermore, surveys can be structured to assess the total health and social needs of individuals and families whereas other types of information reflect program data, which, of necessity, are fragments of the whole. The United States, in implementing the National Health Planning and Resources Development Act (PL 93-641), is committed to a policy of health planning at the national, state, and area-wide levels. Although health planning of this kind is a political activity (using the broadest definition of "'political"), it is essential that we apply usable and valid data to allocate resources if we are to promote the goals of improving access to high quality health care at reasonable cost, as projected by the law. The report by Siemiatycki' has implications for those who have responsibility for implementing the Act. One of the pitfalls in planning as performed at the Health Systems Agency (HSA) level is that there may be great variations in the needs for or utilization of health services within a health service area.3 These variations can be taken into account in health planning only if the data currently available through surveys by the National Center for Health Statistics and other federal health programs, including the Cooperative Health Statistics System conducted at the state level, are supplemented by small area surveys. However, Section 1513 (b) of PL 93-641 enjoins the Health 221
