RELATION
OF
MEDICINE
TO
THE
PROBLEM
OF
RADIOACTIVE
FALLOUT
Lee E. Farr, M.D.
T
HE moral and ethical principles ofmed-icine have been epitomized by the Hip-poeratie Oath for some 2,500 years. In this
pronouncement the individumal physician is
related to tile individual patient by strong
professional and ethical bonds. This
stan-dard of ethical conduct has remained viable through countless social umpiieavals to the present day.
In the meanwhile, the responsibilities and capabilities of medicine have changed beyond belief. For modern societies, the
so-cial and body politic responsibilities of
medicine have never been clearly defined,
althoumgh their existemice has been
repeat-edly acknowledged. The lack of clear
definition of which areas in society as a
whole shoumld have medical counsel, how
this couinsel is to he offered, and how the profession will arrive at an agreement on the scientific contents of this medical
coun-sel is epitomized by this conference in
Which we endeavored to lay bare the facts
which are pertinent and at the same time
determine what, if any, social gumidelines based upon these facts are to he advocated in the body politic.
In medicine, the usages and euistonis of
science have been adhered to whereby the
individual seiemitist subjects new hypotheses and laboratory discoveries to the scrutiny of his colleagues to establish verification and acceptance, correction or, rejection. This procedure has usefulness and validity. Its efficacy is clearly greatest within those
areas where experimental methodology can
be applied to laboratory tests and
experi-ments whicil give promise of yielding the
desired answer. In many areas of
epidemi-ological stumdy, particularly in matters of
concern to us in thus conferemice, there are
no good miiodels for experiments. Yet, pre-dictiomus mumst he made amid advice given on
the basis of the most logical dedumctions
from the facts at huand. The modern
scien-tist is trained in the experimental methlOd;
and, when the experimental method cannot
be applied, hue is at loss how to assess the problem to his own satisfaction.
To examine tue first poimut a bit fumrtluer,
it
is necessary to point ouit that the diseases
\Vhlich remain among popuilation members
after elimination of epidemic infectiouis dis-ease affect a different age group whose dis-ability has a (lumite different impact upomi
the commumnity tiuami was previously the
case. Fuirthermore, the disorders predomi-nating callllot with the means at huand be
readily sumbjected to study amid examination
to yieldl clear and unuequmivocal answers de-nived from experimental procedumres largely
based ill the laboratory, such as was the
case iii ihlmuess caused by imifectioums disease agents amid the specific dietary deficiency diseases. Iii all earlier imustances, caumse and effect as vell as demonstration of
thlerapeul-tie efficacy of any given measure were
closely related! temporally. In the diseases
now becoming of major concern, this close
temporal relatiomushuip does not exist.
Fumr-ther, the caumsative agent is frequiently so
elusive that its nature muist he presuimed
for test purposes. Consequently, the
pres-ence or absemuce of the noxious agent is
often difficult to establish and may not be
I)entillelit iii certain advanced phuases of
disease. Moreover, it is clear we are
be-ginning to he increasimugly concenued with
illnesses resultimug from a qumantitative
in-ter)lay over a variable time interval
he-tween agent or agemuts, host, amid! environ-muiemut, and this interrelationshlip is of an
extremely complex natuire. It has become
unequivocal that in niamuv imistances very
long intervals, of a score of years or more,
niay have to elapse between the time of
suif-ficiemutly mamuifest to permit docummentation.
In other situations, the conditions may be
such that a time intensity factor becomes
very significant. Tiuat is, exposumre to a very
minumte dose comitinuoumsly over a long
pe-nod of time produices noxioums effects
iden-tical with or not greatly dissimilar from
those produced! by a larger dose exposumre
over a lesser interval. The concemutration of
the muoxious agent may never exceed
ap-1)ctrent tolerance levels imi the low close, prolonged exposumre system.
The second factor becoming increasingly operative is that to attaimu the health goals
now sighted, an ever-widening control of
personal actions of the individual citizen
becomes necessary. For example, one need
only to 1)Oimit to the measures institumted in the larger cities, as well as the state of Cali-fornia, to control air pollumtion. The individ-ual is restricted imu his choice of method of Personal waste material disposal, the corpO-ration is restricted in its choice of fuel, the mamiuifactumrer of devices is comustrained to
fliO(!ify these in accordance with statuitory
regulatiomis. In order to make suich
provi-siomis effective and emiforceable, a broad
base of political sumpport becomes mandato-ry. To achieve this requisite political sup-port, tile body politic is more and more
fre-(uiemitly asked to ratify programs advocated
whuich are based umpon specific endeavors of
medical science pertaining to the field
con-cerned. Or alternatively, and this is a
markedly differemit alternative, the body
politic is requmested to approve certain
prin-ciples of action to be taken in respect to
gaining scientific or medical goals. Once
the principles have been approved their
im-piementation becomes an administrative
responsibility. To effectively administer
suich a program requires specific technical
knowledge, not only to accomplish its
ob-jectives but also to imiterpret the broad
so-cial results of suchi implementatiomi. In cm-cumstances whemi approval of principles is the basis for authority, the niod!e of
admimu-istration has usually been left to the cog-noscemiti in tue appropriate field, such as sumpport of medical research by the federal
government. In general, the United! States
has endeavored to follow the course of
ac-tion involvimig approval of pnimuciple, bumt
this has miot always occuirred and numerous examples of courses following specific mea-sures can he cited!, such as flumonidation of vater. \Vhuemi (lumestions of this latter type
are considered, it has been cumstomary for
political proponents and oppomients of a
course of actiomi each to seek out and cite scientific suipl)Ort for his stand as vell as to emihist sciemutists in the active campaign.
This system has worked effectively in
past amid continumes to work effectively
today ‘hen the question at issue is
relative-ly minor iii regard to the major policies of
government and when, the scientific aspects
are very specific, the data clear and the
(luestion at issue iiivolves a single area of action, such as water pumnification or mea-sumres requnning vaccimuatiomi before children
attend pumbhic school. No aetiomi taken in
I)umrsuit of goals estabhisiled for these proj-ects will seniouisly affect imuternational rela-tiomuships. \Vhemi, omu the othuer hand, the quiestions at issue involve
tue
fundamental course to he takemu in the caumse of national self-preservation a by resistimug aggressiomu,the decision must he made in large part
umpon social I)ases vhichu in these matters are equmally valid vith the scientifically on-ented componemits of the (1uestion. In such instamuces, the use of vell-known scientists
to support, omi what is in truth a social
basis, a given stand for or against a certain
policy most frequently results not in
clarification but in obfuscation of the issume. For in this case, the scientific qumalifications on %‘hlich a sciemitist’s repumtation rests are being misumsed as qumahifications in social affairs. No sumChl social qumahification actumal-ly exists by virtue of scientific attainments alone. If the scientific matters be not yen-ties hut assumptions and ded!umctions rather thamu comicrete observations, the confusion is cOmpoummudled.
Yet, iml tile latter situmatiomi, which is cer-taimuly the case imi some qumestions dealing with nuclear weapons, it is clear tilat
legislator is rightly impatiemit with the physician wiuo says that radioactive fallout is harmfuml but will Ilot state explicitly the levels at which specific harm is generated. On the other handi,
it
is equmahly clear that a vise 1)hysiciaml will muot at thus time state defimuite levels below which exposure to ra-dioactive fahloumt need not be reduced. Tuequmestioml is hot one for which we have at
hand data which merely requires
clas-sification in order to provide a clearly
mani-fest answer. At the same time we must
admit tiuat if tue informed physician
re-mains silent the public will receive poor ad-vice in this regard from those inadequmately informed but perhaps withouit realizing this to be the case.
How thuen can thus dilemma be resolved? It cannot be resolved by medicine refuising to give ami answer ummitil all data is in, for iii such a social situation the vacumum thus cre-ated will be filled by others less qumalified to advise. It cannot be resolved by medicine as a profession becoming a part of a pout-ical apparatuis. It must be resolved by
mcd-icine devising mechanisms for action of
qumahified individuals within its ranks that
may effectively disclose thereby where
tue
areas of scientific ignorance exist that this
condition may be remedied; where the
areas exist of knowledge, butt inadequate in
extent and depth to give a reasonably
cor-rect amiswer, that these may be highlhigilted; and ‘here the areas of scientific agreement exist that these may be clearly delineated.
When this type of information evalumation
procedumre is clearly a part of the scientific
information screening procedure for data to
be given to tue public, it will provide also a capability of making estimates of the reli-ability of the conclumsions drawn and these
estimates can be understood by members of
the body politic.
In the present instamlee,
oversimplifi-cation of the matter can also be
danger-oums, for the agreed upon facts may be of
much less importance than the general
hiy-potheses to be derived from and based
upon a demonstration of those facts. The
process must be encoumraged and nourished
of confrontation within medicimue of those
holding comitrary opmniomls relative to tile 50-cia! action inc!icated when the opinions are
based umpomi the same observations. It is
only by free discumssion amomig those best
imiformed thuat a basis for agreed action can
he estabhishued when the absolutes or the
points of referemuce are yet to be precisely
ascertained. Because physicians and
scien-tists are also members of the body politic, and becaumse by study thuey can clearly
nec-ognize the social implications of their
by-potheses, there is a strong temptation to
move directly to thue political arena to umrge adoption of a coumrse of actiomi they suipport
because they believe their interpretation of
facts to be the correct one. Yet, thus tempta-tion muist be resisted, if not in its emitirety, at least umitil exhauistive examination by col-leagumes has certainly modified and altered tue course proposed but more importantly
iuas given assurance that the hypotheses
being promoted under the banner of
mcdi-cine are in accordance with known facts
and are tile most probably correct imiterpre-tations of those facts.
Thums, the constitumemit areas of general
medicine mtmst provide mechanisms by
which physicians and medical scientists can scrutinize in minute detail those facts, and
particularly the dedumctions made
there-from, whuicil are most pertinent to time areas
of their special medical competence. Then,
and presumably by tue same mechanisms,
the compollemit constitument fields of
mcdi-cine can be brouight into some type of
broad agreement and umnion. With sumch an
agreement as a foumndation, it then is not
only proper but also mamudatory for
mcdi-cine to assume its place in the political
arena. If this can be done, there is every
reason to believe the comisequences will be
as fortunate as thiose whuich have resulted from the earlier forays of medicine into the
political arena viuen improvement in the
public health was souight.
In contemplation of qumestions such as
these, one must consider areas oumtside the
arises. For there exist, as I have already stated, excehlemit mechamiisms for testing the validity of scientific and techmuical imiforma-tion, buit questions concernimig the
apphica-tion of scientific advances to society as a
whole have miever been a prime comisidena-tion of any professional group, since per se
they involve a mnuilti-disciplmnary amid
trans-disciplinary approach. Moreover, the
evalu-ation mechianism must be developed to
op-crate at all stages of information gathering relative to a specific issue and not limited to situatiomis in which the major scientific facts are no longer in doumbt or unknown.
Finally, the consideration of these major
endeavors muist he carried out with a
col-leetion, assessment, and cOnsOhid!atiofl of
information so that it may be understood
by tile average member of the group. In
this age of complete specialization, this
alone is an extraordinary task for in many
areas of medical science the ordinary terms of communication used by those in the field
are completely foreign to colleagues in
an-other field of medicine. Hopefully, one
looks to the use of computers as perhaps
giving uis the best chance for resokmtion of
this problem. Tue computer can be
pro-grammed to deliver information inserted in
it iii any given language in amiy other
de-sired compatible langumage. This bnimigs us
really to the heart of the evaluation prob-hem; it is basically one of communicatiomi.
When science is discussed in mixed
groumps, words are frequmently used whuich
were designed for other purposes or by
present usage have acqumired a “value
eon-tent” wilicii suggests some type of moral judgment. It is precisely in this region that
a computer may be of greater asistance for
its langumage muist be constructed for the
transmission of the facts at hand, and it
must be precise. With these two basic
re-(lumirements to be met before its manipuila-tive processes may be used, the compumter,
an instniment capable of storing an
ex-traordinarily large assortment of facts or
bits of knowledge whuich can be retrieved at
will and in any combination, becomes an
imistrument of extraordinary importance in
scientific comuimumuication . \Ioreover, to
cope vitiu the expansiomi of scientific knowl-ed!ge some sumch system of information
ston-age amid retrieval has become mandatory. Imi the expeniemuce of many investigators the muumber of items of information being
intro-(luced into tue medical literature per
annuim now exceeds that introduced earlier
over an entire decade. We have not yet
adapted the mode of emutry of tllese new
items to present day capabilities, yet
capac-ity to enlarge the body of medical
knowl-edge is increasing as rapidly, if not more
rapidly, even than actumal production of en-tries. As a comusequmence, it is the rule for dhscussons to have only a portion of the
available kmuowledge incorporated within
their own body of umsefuml kiiowledge. This has led to a situatiomu iii whuich eminent aum-thuorities have appeared to take opposite views, wiTien, as a matter of fact, they are more in agreememit thami in disagreement. Probably this huas beemu trume in no field to the extent thuat it iuas been observed in the medical-politico discumssiomis about radioac-tive fahlouit. The fact that technical capabil-ity exists to meet the needs of commumnica-tiomi today is most emicouraging for it means
that thus aspect of the problem can be
solved.
If tileli, ve do indeed establish
satisfac-tory worldwide commummuication relative to
storage audi retrieval of observations made
worldwide upon i)oi)uilations as well as in
laboratories, we place ourselves in a posi-tion whereimi
tue
normal and tried mecha-nisms of review, testimig and acceptance, suitable miiodificatiomu, or (liscard!ing can once more come imuto effective play. It thenbe-collies possible for medicimue to speak
aum-thonitatively relative to its concern within this field, amid by so doing eliminate much of the comufusiomu that always arises when many
tomigumes speak out. The concenmu of
medi-cine for people, both as groups amid as indi-viduals, is historic. It has cemented together
insofar as was possibie within its sphere
SUPPLEMENT healthfuml comuditiomis for mnamikimic!. If then
this social comiscience of medicine is
sumfficiemut to drive tue profession into at least a partial solution of the technical problems withu whuichi mankind is faced vis
a
l_)is radiation exposures amid oumt of this sohum-tion provide the facet for a social resolumtionof the questions environmental radiation
exposure gives birth to, we shall be meeting oumr responsibilities. If, however, the social
conscience of medicine drives the
profes-sion fumrther apart so that its centnipetal forces, which have led to specialization
with attendant benefits and hazards,
be-come primarily operative so that each
spe-cial area feels comistrainec! to act as its own spokesman in the politico-social arena, then indeed the qumestions vihl become unresolv-able.
This conference was designed to bring
together individumals interested in wide
spectra of the falloumt problem. It is hoped that a record of its proceedings will throw
light on confusions which have arisen
be-cause of imusuifficient data amid thiat the
rec-ord will clearly delineate gaps in our
knowledge which need to be filled before
we can address oumrselves to the final
solu-tions of the problems which are inherent in
this field. Finally, and muot of least import,
that the proceedings will establish an
au-thlonitative statememut of those parts of the problem that can be clearly defined today.
The American Academy of Pediatrics is
concerned with the child. This meeting is
an endeavor of the Academy to meet its
re-sponsibilities to the chuild and at the same
time to medicine in gemueral. This meeting,
by providimig expert opinion of stumdies of
this most complex manifestatiomi of the phe-nomemia of growth amid development, assists in completion of the picture of effects of
ra-dioactive falloumt and environmental
con-tamination uipon man. Tue pediatrician
nec-ognizes that in this question, as in many
others, he may deal only with the interval dumring which tue activating factor initiates its process and seldom with the final result of interacting forces insofar as the
individ-ual umnder his care is concerned. To gain
proper perspective, therefore, this
confer-ence has brought together scientists in
many medical and scientific specialties as
well as specialists from the field of
commum-nications and govermument that a better
sense of relation of the vanioums interacting groups may be effected.
Whuether for medicine and society, this
conference will be a milestone toward a
new and better system of communication,
evaluiation and opinion making only the
fu-tuire can tell. I trust tiuat each of you has
foumnd participation in tile conference as
provocative, fulfilling and motivating as
have I. On behalf of tue Academy, I wish to
express formally oumr deep indebtedness to
all of you participants for enthusiastic sup-port of this undertakimig that the pediatri-cian everywhere may be better informed
about the medical fundamentals of this
problem thlat better medical care may be
provided for the gemierations yet to come,
as well as those now on tue road between
conception and matumnity.
CONCLUSION
I have one additional item for the
comifer-ence-a recommendation Dr. Josephi
Stern-berg wishes to bring before youm to
deter-mine whether the conference participants are in agreement.
Throughout this conference many participants stressed the pediatric importance of radioactive
isotope contamination before or during
preg-nancy. It is evident that studies of the effects of
ionizing radiation upon the child must be begun
even before the time of conception.
Therefore, this comiference places upomi
the record the recognition of tue great
de-sirability amid need of establishing closer and more effective liaison between appropriate
pumblie health officials,health physicists,
ra-diobiologists, numelear medicine physicians,
