Dr. Elsten is a general practitioner in Anderson, Indiana. This article was prepared as a letter of January 11, 1960, to some of his patients.
Although I have not been directly asked by one of my own patients as to my position on the mass polio immunization program which was organized by a committee of the UAW-CIO, I have had inquiries from some of the public-minded citizens who offered to give aid and assistance to this program. Their questions are important but a proper answer is so long that it is not practical for me to answer in detail every individual who so inquires. In view of this and in the firm belief that each of my patients depends on my medical judgment for the maintenance of his personal health, and the health of his family, each deserves to know how that judgment is applied.
When you or any of my other patients come into my office and asks my advice about a polio shot, my answer is likely to come rather quickly and probably will be, "Yes,
I think it is a protection you should have." Following a few questions which you may not associate with the request you have made, you may get your immunization and be given a return date for your succeeding injections. You have no reason to reflect on the fact that you have called up in my mind an instant review of immunization, its chemistry, its physiology, and its pathology, as well as the pathology of poliomyelitis. My knowledge of your own reactions to prior immunizations and medications, the mathematics of polio attack rates, vaccine reaction rates, a flash review of the known reactions to the different ingredients in Salk vaccine—monkey kidney protein, mercury or quaternary ammonium preservatives, penicillin, as well as polio virus protein, my casual question about asthma and hay fever, hives, and other allergies, penicillin reactions, all have a place in the formation of my judgment.
Suppose my knowledge of you, or your answer to one of my questions, causes me to hesitate—somewhere along the line something suggests that you should not have the vaccine. I must remember that fatal results have followed injections of Salk vaccine for a number of reasons. I must not forget that a number of cases of polio were caused by an earlier vaccine. A failure in processing could cause a repetition, and this tiny mathematical chance must be weighed. You have not had occasion to read as I have the reports of the extreme sensitivity of some people to penicillin—so that only a few molecules have caused critical illness or even death. The same thing applies to mercury, which some brands of the vaccine contain.
Then I have to think of your chance of actually contracting poliomyelitis, if you are, and if you are not, inoculated. Perhaps at your age, your chance is 1 in 50,000 of contracting paralytic poliomyelitis. The full series of Salk vaccine shots at proper intervals would reduce this to 1 in 400,000. On the other hand, if my judgment tells me you have one chance in a thousand or one in fifty or even one in two of reacting unfavorably, I would certainly advise you not to take the vaccine.
When I advise you this way, I will also explain that for the past few years I have been carefully watching the development and testing of the Sabin vaccine—another product of the research for better and safer vaccines against poliomyelitis. I will explain that we are not in a polio season now and that it is possible we may have a better and safer vaccine soon and that this new product will not contain preservatives. The new vaccine of which I speak is given by mouth and does not require any shots at all. The reports of millions of tests in some foreign countries make me hope for a much improved preventative for polio, and while I reserve judgment until more reports are in from tests taking place now in this country, I am guardedly enthusiastic.
My knowledge of you, my records, the answers to my questions, even my judgment of your skin color and general body build, all combine with the training I have had to develop a special professional opinion for you as an individual patient. The same process is repeated for any and all patients and the result may be entirely different. It might even be different for you under other circumstances and at another time.
Under very special circumstances, mass immunization programs may be proper. My judgment would give me a different answer if we were facing a spreading or imminent epidemic, or if the disease in question had a high instead of low attack rate, or if a sequence of events exposed our community to a definite hazard at this time. These variations do not change the process of the technical judgment—they simply change the weight of the factors—so that my best judgment, under different conditions, gives me a different conclusion.
I sincerely hope this discussion has given you a better insight into what I mean when I speak of individual, responsible, medical judgment. I would like now to discuss some matters relevant to the Madison County Polio Immunization Program itself.
It is claimed in our local newspapers that between 11,000 and 12,000 persons have indicated that they wish shots in the mass program. This means, according to the figures, some twenty thousand or more injections are needed to complete the series. The known attack rate for poliomyelitis in Central Indiana recently plotted against a completely immunized group of 12,000 indicates a probability of saving 1/3 of one person from contracting the disease. Since we do not save persons from illness by thirds, it means the whole program has one chance in three of success in avoiding one case of polio (not necessarily severe or fatal) and two chances in three of failure to avoid even one case. On the other hand, the fact remains that in 20,000 injections into an unscreened group, there is a fair chance of some local infections. There is a mathematical chance of severe infection from faulty technique and there is more than a casual chance of a penicillin or mercury sensitivity. This kind of accident could, of course, happen with the best office preparation and technique, but in the case of a mass program, I must add a very husky factor for the type of unexpected happening we associate with all such crash and production line techniques, where preparations are minimal, individualization nonexistent, and frenzy replaces reason.
Other things come to mind, too, in connection with this question. Madison County is well supplied with good doctors, who can adequately take care of their patients. The publicity surrounding the present polio question sets the stage perfectly, it seems to me, for many people to become acquainted with their personal physicians, or in the event they have none, to establish a primary, unhurried, non-emergency contact. I am very certain of one thing, that the most fundamental element in our American system of medical care is mutual responsibility of a personal physician to his patient and that individual patient to his physician. This mutual interest is not served by a scramble for "free" production line care, but by a personal visit by a doctor’s personal patient to his personal doctor.
While I have advised against Salk vaccine in some cases, I have never refused to give an immunization because of inability to pay. The matter of payment for services did not enter into my decision on this matter.
An unusual public impression seems to have developed concerning the role of the Madison County Medical Society. The county society is an educational organization, not a service league or pressure group. Under no circumstances can the society practice medicine, nor can it dictate to its members what they shall do professionally. There is absolutely no mechanism by which the Society could provide medical assistance to a program, or deliver a doctor or group of doctors to perform a service. The most it could do would be to report a consensus that a certain program was or was not deemed proper and desirable. This is precisely what was done in the present case. The request of the UAW Citizens’ Committee was considered, and it was the unanimous professional opinion of those present that the program could not be given approval. The unanimous vote against this proposal was proof positive that not a single member present approved.
In my own case, I voted against approval because I considered the project to be an example of poor quality medical care. It is an unnecessary, potentially dangerous program.
I am sure that the members of the Citizens’ Committee thought they were being helpful to their community and humanity. However, I would like for you to view it in this light.
A group of laymen decided, on the basis of nonprofessional judgment, that there existed a problem of protecting Anderson and Madison County‘s public from the threat of a vicious disease. In their judgment a "cure" for this threat was at hand, and they assumed that the physicians of the community were withholding this available cure.
Evidently they did not realize that the doctors had considered the problem, had weighed it in the light of their professional knowledge and judgment of the subject, and had abandoned it as a slipshod type of medical care to which their patients were not accustomed and should not be subjected.
I know a number of the members of the groups who were working toward this mass immunization program, and I realize it must have been quite a shock to them to learn that every physician present at the meeting which had this program on the agenda disapproved.
One of man’s most driving motivations is to feel superior. He manifests this in many ways and all too commonly gives advice in a special field in which he has no training. The bookkeeper turns sidewalk superintendent, the doctor issues legal opinions, the elevator operator offers stock market advice, and many persons well-trained in their own fields turn amateur doctors. This seems to be legitimatized in many minds if the doctoring includes or touches upon the social welfare field.
This is a vast psychological quicksand which entraps many people. These same people, having failed in their impassioned and fervent enthusiasm to realize that they were completely without basis in technical knowledge for the action they had entered, now reason that since their position was public and they were individually and collectively in the limelight, they would somehow lose face if they requested advice from someone who was not in ignorance of the facts.
The result is that to this day—insofar as I know—they have not asked for medical advice. They have asked only for medical hands to carry out the mechanics of a program of inferior quality which they devised.
I am sure that even now, were the people to ask for medical advice, they would get it. However, they cannot get it from the County Medical Society. This organization cannot give advice. Medical organizations can no more give advice than can corporations. Only people can give advice. A request for such help can be channeled by the Society to one or more of its members for consideration, or doctors may be approached personally and individually for such help. One thing is clear, any medical advice or opinion of value must eventually come from ah individual—and an individual who has the training and knowledge from which to draw reasoned conclusions.
This has been a lengthy letter. However, I want you to know the truth about any issue which involves you and me as partners in the health maintenance activities which is the goal of our mutual responsibilities. This letter presents an outline of the facts as I see them.