Book ideas #6: Polio by David M. Oshinsky
Fundraising initiatives, talent clustering, metascience, and ethical dilemmas
David M. Oshinsky’s Pulitzer Prize-winning book Polio documents how the poliomyelitis epidemic, more commonly known as polio, kept Americans in fear and how a vaccine was eventually developed. Like all great non-fiction books, it’s about much more than its primary focus. Among other things, it helps us better understand how science works behind the scenes, human ambition, ethical dilemmas, innovation, and the importance of incentives. In this post, I pick four such themes from the book and relate them to other ideas.
1. March of Mothers on Polio
The fight against polio was financed primarily by the National Foundation. The charity, created by US President and polio survivor Franklin D. Roosevelt, relied on donations from the public. One of their fundraising initiatives was called the March of Mothers on Polio. Initially started in Phoenix, Arizona in 1950, the idea behind it was simple: Mothers would go door-to-door to fundraise in the neighborhood.
In fundraising initiatives, organizers must tackle two tasks. The first task is to find volunteers to do the fundraising, and the second is to get potential donors to part with their money. Both tasks become easier when people already have a positive predisposition towards the charity’s cause, as was the case in the fight against polio. However, history is full of initiatives that have failed despite the initial popular support. So, the National Foundation needed to get some crucial aspects of its fundraising effort right.
Consider how mothers were recruited and what was expected of them. They only needed to attend an initial coordination session and solicit donations for an hour. It’s worth noting that the National Foundation could have chosen a different approach, one that forced potential volunteers to attend countless coordination sessions or required a larger time commitment. This would have likely had the effect of reducing the participation rate.
Besides the time commitment, the fear of rejection could also potentially dissuade mothers from participating. Most people don’t like soliciting donations door-to-door. After all, getting the door slammed in your face, having a deranged person shout obscenities at you, or simply being rejected or ignored are situations most people find unpleasant. The mothers were spared such fear. In fact, their task could be more accurately described as one of collecting (rather than soliciting) donations. The organizers had widely advertised the fundraising initiative and asked people to signal their willingness to donate by placing a candle on their porch or by turning on their porch light.
The visual signal, aside from alleviating the mothers’ fears, had an additional benefit. It likely encouraged more people to donate. Typically, giving money to a door-to-door fundraiser is a private act, invisible to the broader community. Not in this fundraising effort. Having a light on your porch was visible to everyone, signaling to the community that you cared about polio victims (children). Using the same logic, not having a light could potentially signal that you didn’t care about children.
As more and more people turned on their lights, failing to follow suit could risk social ostracism. In the 1950s, identifying a non-participating household was also much easier thanks to close community ties and less prevalent public lighting.
2. City College of New York and talent clustering
Two types of vaccines were developed against polio: one based on an inactivated (or killed) virus and one based on an attenuated (or live) virus. The main researcher associated with the inactivated polio vaccine was a man named Jonas Salk. The son of working-class Jewish immigrant parents, he completed some of his studies at the City College of New York.
This institution, founded in 1847, was the first free public institution of higher education in the US. Among its notable alumni, we find numerous Nobel Prize winners, successful businessmen, a Supreme Court Justice, and other notable individuals. There were many reasons behind its success, and among them is certainly its ethos of admitting every academically qualified candidate. Unlike other top universities at the time, it didn’t restrict its talent search to a small part of the population who happened to look a certain way or come from a certain background. Rather, it cast a wide net, hoping to identify talent wherever it may be. Among working-class Jewish immigrant families, traditionally overlooked by mainstream talent search institutions, there happened to be an abundance of untapped talent.
The point is not that other top universities didn’t have great students. They did. After all, there have always been more talented students than spots at top places. But we should note that talent search is not a zero-sum game. The great contribution of the City College of New York lay not in playing the zero-sum game of poaching talent from other top places. Instead, it lay in increasing the whole talent pool by giving an opportunity to people like Salk, whose talent would likely have gone to waste otherwise.
3. Metascience
Developing a polio vaccine required significant financial resources. Medical schools, where most of the biological research took place at the time, were heavily reliant on external funds, such as grants provided by the National Foundation, to support a substantial part of their research. On the surface, this looked like a win-win arrangement for all parties. The university and its researchers would secure funding, and the organization would support the scientists they believed had the highest chance of developing a vaccine.
When the Bacteriology Department at Harvard was reluctant to accept a grant from the National Foundation, this allegedly win-win arrangement came under scrutiny. It turned out that while the grant was indeed very prestigious, it also imposed indirect costs on the university (e.g., in the form of higher maintenance and personnel costs). The extra overhead changed the university’s cost-benefit analysis, leading to its initial reluctance to accept the grant.
The National Foundation proposed to cover a portion of the grant-related overhead. Harvard happily accepted the grant with the updated conditions. The concept of adding some extra money to defray the grantee’s indirect costs was then implemented more broadly.
The lesson of this story is that we should continuously experiment with ways to improve the social processes of science. Sometimes, the improvement will come from reassessing the structure of grants or from aligning the funding organization’s incentives with those of the scientists and their host institutions. Other times, progress will take an altogether different shape. As it’s impossible to predict which changes will lead to improvements in the social processes of science, our best bet is to encourage decentralized experimentation and scale those few ideas that showed promise locally.
4. Ethical dilemmas in medical research
Polio was a disease that primarily affected children. On the one hand, this increased people’s willingness to support the fight for a vaccine, evidenced by successful fundraising initiatives like the March of Mothers I discussed earlier. At the same time, this also meant that any potential vaccine would ultimately need to be tested on children.
Human experiments are ethically delicate territory, especially when children are involved. When the possibility of an effective vaccine became real in the early 1950s, the memory of the Nazis’ unconscionable medical experiments was still not far from Americans’ minds. One of the thorniest issues, laid out in the Nuremberg Code of 1947, revolved around informed consent. How can children provide informed consent, if at all?
At the time, it was generally agreed that a guardian or parent could consent on behalf of a child, provided that certain conditions were met. Much more ethically unclear was the case of experimenting with institutionalized children. On the one hand, institutionalized children were ideal subjects from a pragmatic perspective and had been used as experimental subjects many times before. On the other hand, their ability to give informed consent was even more questionable than that of other (non-institutionalized) children.
This ethical dilemma quickly took on practical relevance, as the first polio vaccine trial was conducted on 20 institutionalized children. Before the trial, however, the researcher had first tried the vaccine on himself. The researcher's willingness to potentially risk his own life, juxtaposed with his decision to experiment on a vulnerable group, underscores that extrapolating from a single ethical or unethical act frequently leads to an inaccurate character assessment.
Experimenting on institutionalized children was hardly the only ethically questionable episode in the development of the polio vaccine. For instance, another polio vaccine was tested on prison inmates who received “$25 and some days off their sentence” for their participation. And these were only the small-scale trials, involving a handful or at most dozens of participants.
Large-scale trials come with larger costs, rewards, and ethical issues. The attenuated (live) vaccine, developed by Albert Sabin, was tested on 10 million Russian children. Unlike their American counterparts, Russian children and their parents in the late 1950s lived under a totalitarian regime that placed little value on concepts like patient autonomy and informed consent.
In the instances discussed so far, the ethical issue centered on administering a vaccine to individuals who may not have wanted it. The large-scale testing of the inactivated (killed) vaccine, conducted in the US in 1955 on 1.8 million children, presented the opposite dilemma: withholding the vaccine from those who may have wanted it.
In a proper medical trial (including vaccine trials), some participants receive the actual treatment, while others receive a placebo. Ideally, neither the healthcare providers administering the treatment nor the participants themselves are aware of who received the actual treatment and who received merely a placebo. This design allows researchers to accurately estimate the treatment's effectiveness.
However, when a treatment looks very promising, ethical questions arise about withholding it from the placebo group. This presents a trade-off: withhold the treatment from the placebo group during the trial to accurately estimate the treatment's effectiveness for the benefit of future patients, or provide it, benefiting the placebo group immediately but possibly sacrificing precision in understanding how well the treatment works.
Having to wrestle with numerous ethical dilemmas is in no way unique to the development of the polio vaccine. In fact, many important medical achievements were fraught with similar ethical issues. Even if we morally condemn some of the decisions researchers or doctors made during their discoveries, we should always strive to understand why they evaluated the ethical trade-offs the way they did.