A reader read about the benefit of influenza shots and called her doctor, who told her there was no vaccine in Japan. That seemed unlikely in a country prone to flu epidemics, so she asks why.

It is, indeed, unusual. For the first time ever, a large percentage of the serum manufactured to counteract this year's flu season did not meet the government's rigid standards. By then, it was too late to produce another supply. The shots are generally given in sets of two in October/November for the flu season in January/ February. A single shot is said to be 85 percent effective, but two are recommended. Although flu inoculations are greatly in demand in Western countries, they are not as prevalent here. Efforts were made, however, to see that the available vaccine was given to those considered to be most at risk, among them the elderly, AIDS and chemotherapy patients and people caring for children. While flu vaccinations are not promoted here under the government health program, many feel they should be obligatory, at least for children and the elderly, who suffer most from the disease.

Then why doesn't the government import enough to fill the need? Apparently required paper work and testing would prevent the vaccine from arriving in time to alleviate the shortage. While a diligent search might find a clinic with serum, it would be a little late for this year.

Another reader asks about "orei," gratuities presented to doctors, usually those at hospitals, by grateful patents. Although he has been told they are not necessary -- there is a sign in his hospital saying such gifts should not be offered -- it was quite obvious to him that the custom continues. He wonders if there is a standard amount to give. How can one avoid giving too much, and thereby wasting money, or too little, and perhaps losing the consideration of the doctor.

Foreigners may think of orei as money being "wasted"; most Japanese consider it symbolic appreciation for the doctor's care and attention. The amount will depend on what was done, a visit to an outpatient clinic (not required) or major surgery (50,000 yen to 100,000 yen, but often much, much more, depending on the patient's position and the doctor's prominence. If a friend recommends a specialist at your request, you may discover, as one reader did, that you are expected to give a gratuity (200,000 yen was suggested) or your friend will feel obligated to do it for you -- embarrassment all around. Gifts are generally presented unobtrusively in a plain envelope, perhaps left on a desk after a visit, seen but seldom acknowledged.

Foreigners, who are not expected to understand Japanese customs, are allowed to ignore them. Often, though, a person wants to show appreciation. Then properly wrapped and bagged gifts from home, a bottle of fine wine or liquor, a gift certificate or a present at "ochugen" or "oseibo" can be given instead of cash. However, money should not be overlooked as an appropriate choice. Western people generally prefer to give a thoughtful gift rather than money. It's a cultural thing. Always, a box of cookies or cakes is a nice gesture for the nurses.

There are doctors who oppose monetary gifts. Although they recognize that some patients, hoping to receive VIP treatment, will continue to give gratuities, they claim that gifts have no influence on treatment. One specialist suggests an alternative way to show appreciation: Make a donation to the hospital for some appropriate use such as cancer research. On the other hand, there are doctors who expect a gratuity if they only refer a patient to another doctor. Obviously there is as great a range in expectations as there is in the amount enclosed in the envelope.

While gift giving is not a requirement, patients should at least express appreciation. A doctor under the government insurance program may work more than 80 hours a week, 7 days a week, seeing as many as 100 patients on outpatient days. Remuneration may be around 600,000 yen a month, and is rarely over a million. One specialist, who has not had a day off in two months, says he gets a tremendous sense of achievement from what he does, and that he is gratified when a patient says, or writes, thank you with sincerity. For him, that is enough.