HEALTH: AN INTEGRAL PART OF HUMAN DEVELOPMENT

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HEALTH: AN INTEGRAL PART OF HUMAN DEVELOPMENTAuthor(s): Monique BginSource: Canadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 69, No.4 (JULY/AUGUST 1978), pp. 271-275Published by: Canadian Public Health AssociationStable URL: http://www.jstor.org/stable/41986419 .Accessed: 14/06/2014 20:11Your use of the JSTOR archive indicates your acceptance of the Terms & Conditions of Use, available at .http://www.jstor.org/page/info/about/policies/terms.jsp .JSTOR is a not-for-profit service that helps scholars, researchers, and students discover, use, and build upon a wide range ofcontent in a trusted digital archive. We use information technology and tools to increase productivity and facilitate new formsof scholarship. For more information about JSTOR, please contact support@jstor.org. .Canadian Public Health Association is collaborating with JSTOR to digitize, preserve and extend access toCanadian Journal of Public Health / Revue Canadienne de Sante'e Publique.http://www.jstor.org This content downloaded from 185.2.32.141 on Sat, 14 Jun 2014 20:11:38 PMAll use subject to JSTOR Terms and Conditionshttp://www.jstor.org/action/showPublisher?publisherCode=cphahttp://www.jstor.org/stable/41986419?origin=JSTOR-pdfhttp://www.jstor.org/page/info/about/policies/terms.jsphttp://www.jstor.org/page/info/about/policies/terms.jspEditorial HEALTH: AN INTEGRAL PART OF HUMAN DEVELOPMENT* The Honourable Monique Bgin It is a great privilege for our country to be the host of this meeting and for me to tell you something about the Cana- dian government's approach to primary health care. I take my duties as a representative of the host country seriously enough to know that one does not treat public health professionals like other visitors to one's home. It would be a boring visit if I just invited you to think about the good things. I will say quickly that Cana- Keynote address delivered to the 2nd International Congress of the World Federation of Public Health Associations and the 69th Annual Conference of the Canadian Public Health Association at Halifax, Nova Scotia on May 23, 1978. dians appear to be reasonably healthy compared to other people in Western developed nations. The latest compara- tive study, in 1 97 1 , shows that of 2 1 such countries we rank eighth on a composite index using such factors as perinatal, infant, and maternal mortality rates and those for people aged between 35 and 54. Life expectancy for Canadian men ranked seventh, at 69.9 years, and for Canadian women ranked second, at 76.9 years. With the exception of Eng- land and Wales, all the countries that ranked ahead of Canada on the general scale are small countries with small populations, which make it easier for them to deliver health services. As I said, I realize that I am talking to health professionals. I now invite you to contemplate Canada's problem areas in public health. To get down to specifics, I should change my tone as well as my figure of speech. At a recent meeting between provincial health ministers and my predecessor, four grim problems have been isolated as being in urgent need of study and action. They are alcohol abuse and traffic injuries, and prob- lems involving occupational health and mental health. These are the four horsemen of the apocalypse in Can- adian public health. They have struck down or crushed the hopes of many thousands of our people and cost astronomical sums of money. Another reason why these four prob- lem areas have been singled out is that we believe that something can be done to prevent them from doing so much damage. It will not be easy. It will require a long and hard effort but we believe that it can be done. There has in fact been a shift of emphasis in this country from sickness care to prevention. This involves pro- moting measures that prevent illness and encourage people to take personal responsibility for their health. This emphasis on prevention is just plain commonsense. If the bridge around the bend in the road is about to collapse, you put up a barricade and warning signs. It is not good enough just to send an ambulance and trained medical people to look after victims. Let me take time now to give some small idea of how much damage is being done by each of the major health problems I have singled out. It is just about impossible to estimate the true cost to Canadian society of alcohol abuse. It takes a while just to name the more pressing alcohol-related problems. It is a factor in liver, cardio- vascular, and respiratory disease, and cancer and certain mental illnesses. It is a grim destroyer of society, implicated in crime and violence, family break- down and industrial accidents. It is a factor in poor performance in schools and in industry. Statistics show how important it is to promote occupational health, including job safety. In 1974, 1,415 work-related fatalities were reported, mostly due to accidents. There has been a climb in the number of accidents on the job. In 1974 Canadian Journal of Public Health Vol. 69, July/ August 1978 271 This content downloaded from 185.2.32.141 on Sat, 14 Jun 2014 20:11:38 PMAll use subject to JSTOR Terms and Conditionshttp://www.jstor.org/page/info/about/policies/terms.jspthey accounted for over one million injuries involving loss of work time. Over 11.5 million man-days were lost through this cause in the year, at a cost of over half a billion dollars to em- ployers in compensation assessments. It is estimated that an additional sum of over $2 billion was lost due to occu- pational injuries in terms of such things as lost productivity, material damage, and retraining. Recognizing that seri- ous problems do exist, the federal government has recently established a Canadian Centre for Occupational Health and Safety. An immediate activity of the Centre will be the development of a national information system on the whole spec- trum of occupational health and safety. The Centre will then begin by providing Canada and Canadians with a co- ordinated and integrated information source that up to now has been lacking in this field. The Centre will attempt through information to promote heal- thy lifestyles for all workers and to prompt the individual's own responsi- bility in this area. Automobile accidents are the number one killer if you think in terms of potential years of life lost. Fully 38% of victims are in the 15 to 24-year age group. In 1974, automobile accidents caused injuries to one out of every 100 Canadians, and 28 Canadians out of every 100,000 met their deaths on the road in that year alone. These are appalling figures. If you were to multi- ply that yearly rate by 70, more or less the average life-span, you would arrive at a truly horrifying figure. At that rate most Canadians would sooner or later be hurt in an automobile accident. And to this must be added the heavy cost of automobile accidents - estimated at a quarter of a billion dollars in 1973 to the health care system alone, and in 1974, at a billion dollars in lost work effort and $1.3 billion in property damage. One Canadian in every six is stricken by the fourth of our grim problems, mental illness. Measured in patient days, about 35% of all hospital care is for mental illness, and it is a factor in the illness of nearly half of all patients seen in general medical practice. Suicide is now the second most frequent cause of death among young Canadians between 15 and 30 years of age. It is clear that this is only part of the problem of mental health in Canada. Much more remains unreported, and signs are that things are getting worse. What are we doing about it? What are we planning to do about it in the future? Clearly, government and health pro- fessionals cannot do away with these problems. All of them, and particularly alcohol abuse and traffic injuries, ulti- mately depend on the public. People must do more to promote and maintain their own good health. What profes- sionals and government can do is pro- vide them with the information they need to take up better lifestyles. We can also promote such commonsense things as i safer vehicles and highways, and call for public support of safety mea- sures such as compulsory seat-belt legislation and controls on the advertis- ing of alcohol. It is good news that many are not only more willing than ever before to take their health into their own hands - they demand it. Just look around here in Halifax or any other Canadian city or town. Joggers and cyclists are every- where. Until a few weeks ago there were cross-country skiers as well. Hardly a week passes without local papers ad- vertising the opening of still another sporting goods store, and still more opportunities to take courses in yoga, weight reduction, or giving up smoking; in becoming better marriage partners and better parents; in choosing the right foods for good health and the right strategies for coping with stress. To judge from the displays in Canadian bookstores, you would think that the time-honoured categories of "fiction and non-fiction" are about to be re- placed by "health promotion and non- health promotion". The consumer movement has also reached a high degree of sophistication in the health field. People want to know what they are getting not only in personal health care, but also in en- vironmental health, health promotion, and health research as well. To pro- fessionals and government, these head- long challenges can be a little exhaust- ing at times. But it is well worth the extra time and trouble that profes- sionals and government must spend in explaining things to an alert and knowl- edgeable minority. The important thing is to encourage more to join the ranks of the consumerists. It is also encouraging to see the growing trend for those with common health problems to band together in mutual help associations. These groups now work alongside the more tradi- tional voluntary agencies which em- phasize service to others. We need both kinds of groups to make the most of the great potential of volunteer work, a subject to which I will return later. This brings up the specific problem of what we professionals and government health people can do to encourage the trend of self-help. It is a truism that individuals change more quickly than organizations, including the health care system. What can we do to catch up? First of all, we can see to it that concerned invididuals have the knowl- edge and confidence they need to make sensible choices. These relate not only to their personal lifestyles, but also to the use they make of preventive mea- sures and treatment services, and to their participation in the planning and delivery of health services. Health education must begin in early childhood. Normally, health profes- sionals, and particularly public health nurses, work with parents to help them understand what is best done for chil- dren in these very crucial first years. It is a question not only of what we can do for pre-school children and their fami- lies, but also what we can help them do for themselves. We also have to think about the effect of television on pre-schoolers. Make no mistake about it, for better or worse, television is usually right there along- side the parents in forming the attitudes of very young children. We know this from the pressures the kids can exert on parents to buy a certain kind of break- fast cereal, a special game or doll or hot- rod set. Most parents know what I am talking about. But does this not also indicate that 272 Canadian Journal of Public Health Vol. 69 This content downloaded from 185.2.32.141 on Sat, 14 Jun 2014 20:11:38 PMAll use subject to JSTOR Terms and Conditionshttp://www.jstor.org/page/info/about/policies/terms.jspTV can be used as a useful tool for the health education of our children - and indeed, people of all ages? I suggest to you that it does. And with this in mind, my Department of National Health and Welfare is, at this moment, co- produc- ing a series of television programs to promote good nutritional habits among Canadian children. And I would not be terribly upset if the kids passed along to their parents some of the information they may have gleaned from these programs. Once children enter school, the public health system becomes a more impor- tant direct influence on their lives. Professionals can ensure a healthy school environment, screen school chil- dren for health defects, and provide such preventive measures as immuni- zation and topical fluoride applica- tions. They can instruct teachers and students about the importance of these measures, and participate in school health programs that not only promote healthy lifestyles but also prepare people to look after their own and their families' minor ailments and to make good use of health services. They can, in other words, prepare them to take on more personal responsibility for their own health. At the same time, public health professionals can teach the young to look after others as well as themselves. They can teach interdependence as well as independence. For example, teen- agers can be prepared to serve as volunteers in hospitals, nursing homes, and other places, and, perhaps, to go on from there in later life to help plan and operate health services. We Canadians, in fact, are very proud of our history of voluntary participa- tion in the health field. The action of volunteer workers is at the heart of a great many worthwhile activities in Canadian life. Behind every Canadian in elected office, for example, there is a voluntary political association at the grassroots level. In the health field, there are great numbers of volunteer health agencies and boards, operating at local, provincial, and federal levels. Hospitals in Canada have been mainly operated by voluntary boards of direc- tors, a situation that persists even now that most of their financing comes from government. In most parts of the coun- try, government-financed public health services are also administered by vol- untary boards. There are voluntary health agencies to represent the interests of people with particular health prob- lems, and finally, there have been many opportunities for community participa- tion in numerous task forces, royal commissions, and public hearings on various aspects of health services in Canada. The emphasis we give to self-help measures does not make us any less sensitive to the need to help others. If someone is about to step in front of a speeding car, you normally shout a warning. If it happens to be a small child or any other person who might have trouble negotiating traffic, you go be- yond a warning and lend a hand. In Canada like every other country, there are some who should be given a helping hand in health matters. Some who have only limited opportunities to adopt healthy lifestyles and only a limited ability to meet their own health needs. They are deprived in relation to other Canadians because of age, poverty, living in isolated places, cultural dif- ferences or physical handicap. Our Canadian sense of interdepen- dence reminds us that we must help them overcome the special obstacles they face. I can only take up two examples today - the poor and the aged. I do not have to remind you that the two groups are by no means mutually exclusive. I am a little abashed to admit that it is only in 1980 that we expect some exact measure of the current relationship between ill-health and poverty in Can- ada. That is when we expect the first results of the Canada Health Survey undertaken jointly by Health and Wel- fare Canada and Statistics Canada. In the meantime, it appears safe enough to operate on the sad assumption that the poor suffer more illness and die at a younger age. That is what was indicated in the Canadian National Sickness Survey of 1950-51 and has been shown in more recent studies in Britain, France, and the United States. There is also good reason to believe that the poor do not benefit as much as other people from Canada's health care services. The results of studies we have from Ontario, Quebec, and Saskatche- wan are a little ambiguous, but they do give us some relatively reliable insights. It seems that the poor visit the doctor more frequently and use more of other health services - except for dental work, for which there is usually no public insurance program. However, there is a big catch to this. Indications are that the poor do not benefit as much from these services because of their living and working conditions, the difficulty they have in getting access to care, lack of education and failure to appreciate preventive measures, and sometimes because they receive in- inferior medical treatment. It is not a cheerful picture. I see hardpressed people, full of trouble, running to the clinic in times of illness and misfortune. I see those who some- times do not get the kind of first rate treatment that every person deserves and who are not able to change the conditions that make illness and acci- dent occur frequently, and make re- covery a slower and more agonizing process. I see those who must put off dental treatment until better times, which may be very slow in coming. We have to face the fact that although our health insurance programs have made it much easier for poor people to have access to medical care, we cannot break the cycle of poverty and illness through the health care system alone. The poor must have more money. They must be able to live in better housing and eat better food. Their work condi- tions should be healthier, and they should have better facilities to make the most of their leisure time. They should enjoy the benefits of an education that will allow them to value their health more and take advantage of preventive measures. In other words, the way to make sure that poor people make better use of the health system is for them to have more July/ August 1978 273 This content downloaded from 185.2.32.141 on Sat, 14 Jun 2014 20:11:38 PMAll use subject to JSTOR Terms and Conditionshttp://www.jstor.org/page/info/about/policies/terms.jspof the blessings of affluence - including money. Another aspect concerns the poor and nutrition. We have plenty of food in Canada to meet the needs of every Canadian. We produce an abundance of nutritious food and import many good things that we do not produce. Our food industry is very efficient. There is nothing in the industry to prevent food from being readily available for all throughout the country, except perhaps for certain inaccessible areas in the far north. The only obstacles are personal or eco- nomic. Some do not know or care about nutrition, or, in the case of native people, are in the course of cultural transition, and others do not have enough money to buy the right things to eat. We share with other Western coun- tries the problems of inflation and unemployment that leave significant numbers of families with very low incomes. This means that many Cana- dians do not have enough money to share in this abundance. A specifically Canadian problem springs from our geographic situation. We are the second largest country in the world in terms of land mass, but most of our population is concentrated within a belt 100 miles wide and 5,000 miles long. Those who live outside this corridor may find the cost of transportation of everyday foods so high that in fact they have to do without things they need for good nutrition. Many of the residents of these outlying areas are native peoples, In- dians and Inuit. For them the problems of low income and high cost are compounded by their unique status of being in a stage of cultural change. So, as you see, things are harder for the poor, and harder still for the poor living in outlying areas. While it is true that the number of families living below the poverty line has declined during the last ten years, the challenge still remains to narrow the gap between the health status of higher and lower income groups. The first line of attack will have to be through social policies such as family allowances, pensions, and social services legislation. But there is also an important role for health activities, and particularly those dealing with pre- vention and education. We cannot let things stand as they are. It is absolutely intolerable to every Canadian that a child born into a poor family not only is likely to remain poor but is also likely to be less healthy during a shorter lifespan. I should say here, in parenthesis as it were, that poor and rich alike are affected by the problem of poor nutri- tion in Canada. Canadians tend to be obese and sedentary. They eat too much of the wrong kind of food and do not take enough exercise. As I pointed out before there is a sizeable minority that is developing a cult of good health. But the fact remains that far too many Canadians suffer from poor nutrition in the midst of plenty. The Canadian government is currently working on a coordinated health education program based on what we believe is sound food and nutrition policy. We believe that this will eventually have a considerable effect on the health of people at all economic and educational levels. In a campaign of this kind, public health nurses in particular can do a great deal of good with their access to the mothers of young children and their involvement in school health programs. The old people have a number of problems all their own. One of Canada's leading public health figures, Dr. Cope Schwenger, has suggested that we are "on the verge of a geriatric crisis". In part this is based on the projections of Statistics Canada that by the year 203 1 the percentage of those over 65 in this country will have doubled from today's 8%. Another projection is that there will be a 300% increase in the number of those over the age of 85 by that time. This may place a very severe demand on institutions for the aged and on health- care systems. At present 10% of those over 65 and 25% of those over 85 are in institutions. Studies of health care utili- zation in Quebec for the year show that the over sixty-fives needed more than twice as many services from physicians than the under sixty-fives. However, I know that Dr. Schwenger implied more by using the phrase "geriatric crisis". No doubt we will be hardpressed to provide all the health and social services required by our elderly citizens, but even more impor- tant, we will be faced more than ever with the need to understand and to strive to alleviate the loneliness, isola- tion, and poverty which affect many of these older Canadians. It is true that some older folk, like the younger Can- adians about whom I spoke earlier, demonstrate an impressive desire and ability to meet their own needs. But there are others who, through no fault of their own, are unable to do so. Those of you who are public health workers do not need to be reminded of the growing numbers of the old among the populations you serve. You will be aware also that the majority of older Canadians are women, many of them widowed. In fact, over 60% of women over 75 are widows. Since relatively few of these women participated in the labour force long enough to acquire pensions, and since many of their husbands' pensions were drastically reduced or even eliminated altogether when their husband died, they are frequently dependent on the Old Age Security Pension - a universal pay- ment to all those 65 years and over - and the Guaranteed Income Supple- ment, which is a means-tested benefit program. Again, I would suggest that, par- ticularly in times of inflation, some of the health needs of the elderly will be alleviated as much by economic secur- ity as by health care. Nevertheless, we all have a responsibility to demonstrate our commitment to interdependence by our special concern for the well-being of these Canadians who have contributed and, to the extent they are able, con- tinue to contribute to our generally affluent society. I hope that this has not been too strenuous a tour of the parts of our Canadian home in need of repair, or at least of very attentive maintenance. I repeat here that in comparative terms at least we have a healthy enough popula- tion. I can add that we also have an impressive health-care system with re- spect to such things as the supply of 274 Canadian Journal of Public Health Vol. 69 This content downloaded from 185.2.32.141 on Sat, 14 Jun 2014 20:11:38 PMAll use subject to JSTOR Terms and Conditionshttp://www.jstor.org/page/info/about/policies/terms.jspacute care beds and the number of health workers, although here I must confess that problems remain in the distribution of health services. What I have tried to do is to suggest ways in which we might prepare people to make better use of our health care resources by looking after their own health, when possible, and to point out that in a general climate of relatively good health there are some who need and deserve assistance from all their fellow Canadians and particularly from those of us who are in the field of health care. Thank you very much for the oppor- tunity to make my views known to you. The Honourable Monique Bgin Minister of National Health and Welfare, Ottawa, Canada K1A 0K9 LA SANT: PARTIE INTGRANTE DU DVELOPPEMENT HUMAIN* C'est un privilge pour notre pays d'tre l'hte de cette rencontre et gale- ment pour moi, de pouvoir vous parler de l'approche du gouvernement cana- dien en matire de soins primaires. Je prends mon rle de reprsentante du pays hte assez au srieux pour savoir qu'on ne reoit pas des pro- fessionnels de l'hygine publique com- me de simples visiteurs sous notre tot. Ce serait ennuyeux si je ne vous invitais qu' penser aux bons cts. Je dirai rapidement que les Canadiens semblent en assez bonne sant par rapport aux autres pays industrialiss de l'Ouest. La dernire tude compara- tive qui remonte 1971 indique que sur 21 de ces pays, nous nous situons au huitime rang d'un indice composite utilisant des facteurs comme les taux de mortalit prinatale autant infantile que maternelle et ce, pour des personnes ges de 35 54 ans. Pour ce qui est de l'esprance de vie, nous sommes septi- mes pour les hommes avec 69.9 ans et deuximes pour les femmes avec 76.9 ans. l'exception de l'Angleterre et du pays de Galles, tous les pays qui devancent le Canada l'chelle gnrale sont des petits pays possdant de faibles populations, et o il est donc plus facile de fournir des soins. Pour en venir aux faits, je devrais peut-tre changer de ton et de manire de m'exprimer. Lors d'une rcente ren- contre entre les ministres provinciaux Discours prononc au 2e Congrs International de la Fdration mondiale des Associations de Sant publi- que et la 69e Confrence annuelle de l'Association Canadienne d'Hygine publique Halifax, Nouvelle- cosse, le 23 mai, 1978. de la Sant et mon prdcesseur, quatre problmes graves demandant tude et action immdiates ont t dgags. Il s'agit de l'abus de l'alcool et des acci- dents routiers, et des problmes relatifs l'hygine du travail et l'hygine mentale. Ce sont les quatre cavaliers de l'Apocalypse en ce qui concerne l'hy- gine publique au Canada. Ils ont tu ou annihil les espoirs de plusieurs milliers de personnes et entran des dpenses astronomiques. Une autre raison qui fait que nous ayons isol ces quatre problmes, c'est que nous croyons qu'il y a moyen de faire quelque chose pour rduire leurs ravages. Ce ne sera pas facile. Il faudra un effort vaillant et soutenu mais nous croyons que c'est possible. En effet, on insiste maintenant da- vantage au Canada sur la prvention que sur le traitement des maladies comme telles. cette fin, il faut sensi- biliser la population des mesures permettant de prvenir les maladies et l'encourager assumer la pleine respon- sabilit de sa sant. Insister sur la prvention, c'est la logique pure. Si un pont est la veille de s'crouler, on place une barrire et des panneaux d'avertissement. Il ne suffit pas d'envoyer une ambulance et des experts pour s'occuper des victimes. Permettez-moi maintenant de vous donner une ide des ravages causs par chacun des principaux problmes sani- taires que j'ai souligns. Il est peu prs impossible d'valuer les vritables cots du flau de l'alcool pour la socit canadienne. Cela prend dj trop de temps pour numrer seulement les principaux problmes lis l'alcool. La boisson est un facteur dans les maladies du foie, cardio-vasculaires et respiratoires, dans le cancer et cer- taines maladies mentales. Elle sape la socit en plus d'tre l'origine de crimes et violences, de l'effondrement de familles et d'accidents industriels, et un facteur de pitres performances l'cole et dans l'industrie. Les statistiques montrent comment il est important de promouvoir l'hygine du travail, y compris la scurit. En 1974, 1,415 dcs lis au travail, la plupart des suites d'accidents, ont t rapports. Le nombre d'accidents au travail augmente. En 1974, ces accidents ont caus plus d'un million de blessures avec temps perdu. Plus de 1 1.5 millions journes-hommes ont t perdues en raison d'accidents durant l'anne, un cot de plus d'un demi-milliard de dollars pour l'employeur sous forme d'indemnits. En outre, on estime plus de 2 milliards de dollars les pertes dues des accidents au travail en termes de productivit perdue, dommages mat- riels et formation des remplaants. Conscient de la gravit des problmes auxquels il a faire face, le gou- vernement fdral a cr rcemment le Centre canadien de l'hygine et de la scurit du travail. L'une des premires tches du Centre sera de mettre sur pied un rseau d'information l'chelle nationale en matire d'hygine et de scurit du travail. Le Centre sera ainsi en mesure de fournir au Canada et aux Canadiens, d'une faon intgre et July/ August 1978 275 This content downloaded from 185.2.32.141 on Sat, 14 Jun 2014 20:11:38 PMAll use subject to JSTOR Terms and Conditionshttp://www.jstor.org/page/info/about/policies/terms.jspArticle Contentsp. 271p. 272p. 273p. 274p. 275Issue Table of ContentsCanadian Journal of Public Health / Revue Canadienne de Sante'e Publique, Vol. 69, No. 4 (JULY/AUGUST 1978), pp. 265-344Front MatterEditorial/ditorialEditor's Desk [pp. 267-267]HEALTH: AN INTEGRAL PART OF HUMAN DEVELOPMENT [pp. 271-275]LA SANT: PARTIE INTGRANTE DU DVELOPPEMENT HUMAIN [pp. 275-279]A Challenge for Human Development: Primary Health Care [pp. 280-283]Outside CanadaKazakhstan: a Land Transformed [pp. 284-285]Amoebiasis Survey in Calcutta (India), Bangkok (Thailand), Medellin (Colombia), and San Jos (Costa Rica) [pp. 286-288]Health TopicsSafety Restraints for Children in Automobiles: Who Uses Them? [pp. 289-292]Problems in Scoliosis Screening [pp. 293-296, 301]Impact of Specialty Centres on Neonatal Heart Disease, Ontario, 1975 [pp. 297-301]Attitudes of the Public towards Cigarette Smoke in Public Places [pp. 302-310]Sexual and Contraceptive Attitudes and Behaviour of High School and College Females [pp. 311-314]Drinking Behaviour among Saskatchewan Adolescents [pp. 315-324]The Measles Epidemic in Calgary, 1974-1975: The Duration of Protection Conferred by Vaccine [pp. 325-333]Meetings &Conferences [pp. 335, 337-338]Back Matter