00:12
Dr. Jane Caldwell
Hi, this is Jane Caldwell. Welcome to the On Medical Grounds podcast, your source for engaging, relevant, evidence-based medical information. We’re hosting a three-part series on polio, a serious disease that was almost totally eradicated in my lifetime due to polio vaccination programs worldwide. We’ll be talking to polio survivors, healthcare providers who cared for polio victims, and a noted expert on polio vaccines.

Today is part one of Polio Confidential: Stories from Those Who Lived It, The Continued Path Toward Prevention. Today I’m speaking with Dr. Paul Offit. Dr. Offit is a professor of pediatrics and an attending physician at the Division of Infectious Diseases at the Children’s Hospital of Philadelphia. As director of the Vaccine Education Center at that institution, he is an internationally recognized expert in the fields of virology and immunology. Dr. Offit is a member of the FDA Vaccine Advisory Committee. In 2011, he wrote “Deadly Choices: How the Anti-Vaccine Movement Threatens Us All.” This book was selected by Kirkus Reviews and Booklist as one of the best non-fiction books of that year. More recently, he has written “Tell Me When It’s Over: An Insider’s Guide to Deciphering COVID Myths and Navigating Our Post-Pandemic World.”

Hello Dr. Offit. Thank you for joining us today.

Dr. Paul Offit
Thanks for asking me.

01:54
Dr. Jane Caldwell
Before we talk about polio, I’d like to ask a few general questions for our listeners so they know who you are and where you’re coming from. First, I’d like to take you back to 2008 when you published a book called “Vaccinated: One Man’s Quest to Defeat the World’s Deadliest Diseases.” You were friends with Maurice Hilleman and you interviewed him extensively for that book. His vaccines have been credited with saving millions of lives. How did he shape the way you view vaccines and infectious disease?

Dr. Paul Offit
Well, he was this brilliant man who really was the principal, either inventor or developer, of nine of the 14 vaccines that we give to infants and young children. It’s just a remarkable, in many ways unimaginable, accomplishment. It’s like trying to imagine a fourth or fifth dimension. He had been a friend for 20 years and in October of 2004, he was diagnosed with disseminated cancer and given roughly six months to live, which is exactly how long he did live. He lived till April of 2005. And, you know, I asked if it would be okay with him if I would interview him periodically during that time. And I did about maybe 65 or 70 hours of interviews just to get his life story. And he was nice enough to allow me to do that. But he was an inspiration. He was never satisfied. He was this sort of brilliant man who was never satisfied. And even on his death bed, he just, his regret was that he didn’t do more.

03:28
Dr. Jane Caldwell
You’ve published over 160 scientific articles and written at least 11 narratives; narratives concerning medical misinformation and the risks and benefits of science. I know physicians live very busy and complicated lives. Why take the time to write and publish? What do you hope to accomplish?

Dr. Paul Offit
Well, I enjoy writing, and I sort of get up every morning early around 4:30 and write for a couple hours before I go into work. It’s to try and influence thought. I do think we’re sort of standing on the precipice right now. Where in some ways science is losing its place as a source of truth. People are just declaring their own scientific truths. And I watched the anti-vaccine movement really grow bigger and better funded. You could argue that with the possible succession into Health and Human Services by Robert F. Kennedy Jr. or the pick of Dave Weldon as head of CDC that the anti-vaccine movement has moved into the mainstream. And I think children are going to suffer for that. So I write to try and prevent that.

04:35
Dr. Jane Caldwell
To me, your narratives seem balanced because you discuss not only the benefits of science, but some of the downsides and risks. On a technical note, for our listeners, how do advisors, say the CDC and FDA, decide when things have gone too far and are too risky, especially in the vaccine world?

Dr. Paul Offit
Well, there are many examples of that. I mean, you look at, for example, just with the COVID vaccines, we had the two mRNA vaccines of Pfizer and Moderna in December of 2020. Two months later, we had a different vaccine, Johnson & Johnson’s vectored virus vaccine, which was found fairly quick to be a very rare cause of something called blood clotting, including clotting in the brain, including fatal clotting in the brain. It was very rare.

But was real. And so you had now these two different vaccines, one of which didn’t cause fatal reactions and one of which did. So I think it became clear that that vaccine had to come off the market, and we did the same thing with the oral polio vaccine. I think we got to the point where more cases were caused by the vaccine than were caused by the wild type virus in this country. And so we had to get away from that oral polio vaccine and did by the year 2000.

05:45
Dr. Jane Caldwell
Many of your writings are medical histories, and one of your first books was about polio. Could you briefly outline the history of polio and the discovery of the first polio vaccine by Jonas Salk?

Dr. Paul Offit
Right. Polio would, at its worst, cause as many as 50,000 cases of paralysis and 1500 deaths a year. More typically, it was 20 to 30,000 cases of paralysis. It was often children five to nine years of age that were paralyzed, and they were paralyzed for the rest of their life. And those who had paralysis of the respiratory muscles had to be put in iron lungs. Some of them were put in iron lungs for decades.

I happened to actually be in a polio ward when I was five years old at the Kernan’s Hospital for Crippled Children. I didn’t have polio, but I had a failed operation on my right foot from a congenital abnormality, which landed me in this ward. You know, it was like a Dickensian experience. You know, there was only one visiting hour a week on Sundays from two to three. I saw children in iron lungs. I saw children in traction who were getting these so-called Sister Kenny hot pack treatments where we take these excruciatingly hot packs and put them on withered arms and withered legs in hopes of restoring movement. And so children were screaming, children were in iron lungs, you know, parents weren’t there, and it was just living hell and that is my recollection of polio and it’s certainly not a time where that we want to ever go back to.

07:19
Dr. Jane Caldwell
Wow. The polio vaccine was developed at a time when our society was embracing science. Antibiotics were in production for the first time, so infectious diseases were on the decline, but polio was still ravaging children. There was this long campaign of information on the polio eradication effort. When the vaccine was declared safe, I was told that church bells rang and loudspeakers in stores would announce the news and people jumped on it. People lined up for their children to get it. How is this different from our environment today?

Dr. Paul Offit
Well, it couldn’t be more different. I mean today. Back in Jonas Salk’s time, when he invented a vaccine, which he did by taking polio, growing it up in cells, purifying it, and killing it with the chemical. And that vaccine worked. And it’s really, really very much like the vaccine we use today. He was a hero. He had ticker tape parades. Now, if you’re an inventor of a vaccine or a co-inventor of vaccine, you’re considered a bad guy. It’s a very, very different time. I think part of it was just people were much more society-minded.

I think the focus wasn’t as much on the individual then. We thought of ourselves as a group, as part of a whole, which I don’t think we think of today. And there was just enormous distrust today, distrust of the whole public health infrastructure, whether it’s FDA, CDC, NIH, people are just very quick to reject that and to reject expertise and to reject experts. And it’s a troubled time.

08:55
Dr. Jane Caldwell
I’d like to talk briefly about the Cutter incident. In April 1955, more than 200,000 children in five states received a polio vaccine that was defective and actually contained active virus rather than attenuated virus. And within a month, that first vaccination program against polio had to be paused. Can you explain to us what went wrong and what the government could have done to prevent that?

Dr. Paul Offit
Well, at the time, we just didn’t really have an infrastructure for vaccine regulation. There were sort of some people at NIH that while doing their other research would sort of supervise programs like Cutter’s. And it was the birth of vaccine regulation in the U.S. The problem was a filtration problem. So poliovirus grows in cells, and it was inactivated or was supposed to be inactivated with formaldehyde, a chemical, but because there was an inadequate separation of the virus from some cells and cell debris, some of the virus hid in those cell debris. And so the formaldehyde wasn’t able to get to the virus. And when that was realized, then the process was changed, and it wasn’t a problem anymore. But it was a killed vaccine that wasn’t killed. And as a consequence , a couple hundred thousand children were inoculated with live fully virulent polio virus. Some suffered, or many suffered, abortive polio, meaning short-lived paralysis. Many suffered permanent paralysis, and 10 people were killed. I think it was probably the worst biological disaster in this country’s history. And it’s amazing to me nobody knows about it. It really was that bad. Imagine something like that happening today.

10:32
Dr. Jane Caldwell
That’s my next question. Even after that Cutter incident, many parents went back to vaccinating their children. Do you think parents now would be willing to go back after an incident like that?

Dr. Paul Offit
They’re not willing to do it now with vaccines that are safe and effective. So, no, I think it was a different time. You’re right. I mean, people trusted, they trusted the companies to figure it out. They trusted the federal agencies like the FDA and CDC to supervise it. And even when it had gone horribly, horribly wrong, they still trusted them to get it right. It was just a very different time than today where we are enormously distrustful in situations where we shouldn’t be distrustful.

11:12
Dr. Jane Caldwell
Would you describe the Cutter incident as maybe the birth of the modern anti-vax movement?

Dr. Paul Offit
I don’t think so, because just for the reasons you said, I think people still trusted and still got vaccinated. Very quickly, we vaccinated the population with polio vaccine. No, I think the birth of the modern American anti-vaccine movement was in the early 1980s with a TV show called DPT Vaccine Roulette, which falsely claimed that the whooping cough or pertussis vaccine was causing permanent disabilities. It was done by a woman named Lee Thompson, who was a reporter then, and it just had enormous impact. People thought, my God, this vaccine isn’t doing what it’s supposed to do. It’s not, not only not necessarily protecting against whooping cough, it’s causing these horrible neurological disorders like epilepsy and others. And it really changed the landscape here, I think. And DPT, there was a group called Dissatisfied Parents Together, which eventually became the National Childhood Information Center, National Vaccine Information Center.

And it was off to the races. Companies were sued and sued and sued. We had to put in the National Childhood Vaccine Injury Act to at least partially prevent these companies from this frivolous civil litigation. And, you know, it never was true, which is interesting is that that vaccine didn’t cause permanent disabilities, but it took, even though study after study showed that it didn’t, it didn’t matter. It had already been put into the consciousness of people in this country. And it was off to the races. The anti-vaccine movement
was born.

And now after the pandemic, it’s even better funded and even more influential and has now risen up into the top tier of government with people like Robert F. Kennedy Jr. being considered as being head of, or, Secretary of Health and Human Services when he said, he has said on a recent podcast, when asked the question, is there any vaccine that you consider beneficial? He said, “No.”

13:06
Dr. Jane Caldwell
What do you think motivates anti-vaxxers?

Dr. Paul Offit
I think for most, it’s a real belief that vaccines have caused harm. Vaccines are given to many children, more than 90, 95 % of children in this country, and they are designed to prevent vaccine-specific, vaccine-preventable disease, specific viruses and bacteria, but they don’t prevent everything else that occurs in life. And there’s often these temporal associations between when a child got a vaccine, and then had a problem. I’ll give you a perfect example. My wife is a private practicing pediatrician.

She went into the office on a weekend and was helping the nurse vaccinate the children because they were getting behind. So there was a mother holding a four-month-old on her lap. While my wife was drawing the vaccine up into the syringe, the child had a seizure and went on to have a permanent seizure disorder, epilepsy, and actually died of a chronic neurological disease at age five. If she had given that vaccine five minutes earlier, I think there are no amount of data in the world that would have convinced that mother of anything other than vaccine caused the problem, right? Her child gets a vaccine, has a seizure, now has a permanent seizure disorder, now is dead of a chronic neurological condition. The vaccine caused it. I’m the mother of a vaccine-damaged child. And that’s what you’re up against. You’re up against these emotional temporal associations and you’re trying to defeat them with statistical arguments.

14:23
Dr. Jane Caldwell
Let’s talk about polio. Has polio been eliminated? And if not, what is its present status, both in the U.S. and globally?

Dr. Paul Offit
So certainly polio, natural polio, still exists in the world, it’s in like Afghanistan, Pakistan. The problem is, and it’s not discussed as much as it should, the oral polio vaccine had a problem which wasn’t trivial. This was the vaccine that was invented by Albert Sabin that came onto the market in the United States in the early 1960s. And it was great. It was cheaper. It could be given by mouth. There was something called contact immunity, meaning you would actually shed vaccine virus in your feces and therefore with hand-mouth behavior, there was about 25 % of people in the home would be vaccinated. Even if you didn’t vaccinate them, that’s contact immunity. And it could be given without requirements, it wasn’t a shot, so it didn’t require sort of sophisticated medical personnel to give the vaccine. And it eliminated polio from the U.S. By the 1970s, polio was gone from the US. But this vaccine could itself cause paralysis and it caused paralysis in eight to 10 children every year. And throughout the 1980s and throughout the 1990s, the only cause of polio in the United States was the polio vaccine. So we then replaced that back essentially with the Salk vaccine, the inactivated vaccine in 2000. And that’s the only vaccine we’ve been using for the last 25 years.

But the virus that could revert to essentially a paralytic type, the oral polio vaccine could mutate back to essentially a virus that could cause paralysis, the so-called, you know, revert virus. Though that’s still in sewage samples, still around. That virus that could cause paralysis is still around. And that’s what happened in Rockland County, New York in 2022, when a 27-year-old man living in an area that had immunization rates less than 30 percent against polio, got polio. And, you know, as you know, with polio, only about one in 200 people at most who are infected with polio are paralyzed. When you see a case of paralysis, you can assume it’s the tip of a much larger iceberg. And when they looked in wastewater samples where he lived, Rockland County and suburban counties, they found that virus. And I think if you looked in Philadelphia, you’d see it, or Chicago or LA, I think that reverting virus is around. He was infected with a type two reverting vaccine strain. And that’s what’s happening in Gaza right now. That’s what’s causing paralysis. It’s not a wild type of virus. So I think that’s the sort of Faustian deal, if you will, that we made with the oral polio vaccine that was made by Albert Sabin.

17:01
Dr. Jane Caldwell
Is polio a particularly dangerous and insidious disease, even today?

Dr. Paul Offit
Well, it affects healthy children and many are permanently paralyzed. I can tell you no disease was more feared when I was a child in the 1950s than that virus. I mean, my parents would not let me go to a public swimming pool. I had to swim with my two cousins in that little sort of plastic pool that you’d wade in in the backyard. That’s where me and my two cousins swam.

And it really is the birth of summer camps. I think that those summer camps in upstate New York, for example, New Hampshire, Vermont, Maine, those were born at the polio epidemic. Parents wanted their children out of the city in those summer months because it was a summer plague, if you will.

17:50
Dr. Jane Caldwell
As you know, most of the people who directly cared for polio patients are no longer alive, and most of the individuals who survive polio, excuse me, most individuals who survive polio in this country are older. How does that impact our current society and how we view polio? Have we just forgotten?

Dr. Paul Offit
We forgot. I think people don’t remember this disease. I think they just see it as a series of black and white pictures of children from long, long ago. And it’s too bad because I think it’s not just that we’ve eliminated polio, we’ve eliminated the memory of polio. And with this case now in Rockland County a couple of years ago, I have a fear that if people think, well, why am I vaccinated against this virus? I don’t even see this disease anymore. Let immunization rates drop low enough and polio will come back.

18:40
Dr. Jane Caldwell
There’s a lot of talk in the media and among healthcare professionals like yourself about a potential resurgence of polio and other vaccine preventable diseases due to the rise in the anti-vax movement and the incoming political administration. Should we be afraid?

Dr. Paul Offit
Yes, we should be very afraid. I think you’re seeing a dramatic increase now in cases of measles and in outbreaks of measles. We had an outbreak recently in Philadelphia. There was an outbreak of 85 children in Columbus, Ohio recently. You’re seeing a five-fold increase in pertussis or whooping cough. In the past year, we had 200 deaths in children from influenza, which is very high. I think the CDC recently published data showing that a larger percentage of parents are exempting their children from getting vaccines in kindergarten than ever before.

There are 14 jurisdictions where more than 5 % of kindergartens were exempted or their parents had exempted them from getting vaccines using philosophical exemptions or religious exemptions. And that has dropped below the level of herd immunity. So now we’re seeing these outbreaks occur. I think they’ll only get worse.

19:45
Dr. Jane Caldwell
How much control does a political administration actually have on vaccine approval and recommendations?

Dr. Paul Offit
They have a lot of power. So for example, it could be that a company would submit a vaccine for licensure. The FDA could say, I think this should be licensed. The CDC could say, I think this should be recommended. And the head of Health and Human Services could say, I don’t think it’s been studied enough. The head of Health and Human Services could say, I want to take these vaccines out of the Vaccine Injury Compensation Program and subject them to the slings and arrows of outrageous civil litigation and then watch what will happen.

Those vaccines will also come off the market. Vaccines aren’t big money makers for these companies. They’re given a few, once or a few times in a lifetime. They’re never going to compete successfully with, you know, diabetes drugs or psychiatric drugs or lifestyle products and, and lipid lowering agents, which are taken every day. So you’re going to, you know, this is a very friable market, if you will. It’s a fragile market. And I think these companies could drop vaccines in a second.

20:52
Dr. Jane Caldwell
As an older American, I got my polio vaccination in the 60s. Should I get a booster?

Dr. Paul Offit
No, you’re good. I think if you were fully vaccinated, good. I mean, it’s a long incubation period disease. All you need is immunological memory, and you likely have immunological memory that will last for a lifetime.

21:11
Dr. Jane Caldwell
Good to know, good to know. What would you recommend that a healthcare provider say to a patient or a patient’s parents who might be questioning vaccine safety?

Dr. Paul Offit
Well, I think it’s reasonable to question vaccines. I mean, we give them to healthy children. I think it’s reasonable to be skeptical of anything you put into your body, especially vaccines, which are biological agents. But you shouldn’t be cynical. You know, I mean, you should be willing to accept that there are data showing efficacy. There are data showing safety, that there are systems in place like the Vaccine Safety Datalink or the V-Safe system or others that are there to pick up rare events if they occur. So, I mean, look at the mRNA vaccines. I mean, that issue of myocarditis was picked up very quickly. And even though it was very rare, like one in 50,000 was picked up very quickly. So there are systems in place to sort of ensure safety because they have to be in place because we give vaccines to healthy children. So we have to have those kinds of systems.

22:05
Dr. Jane Caldwell
COVID-19 deaths greatly outnumbered polio deaths, yet there was a massive spike in the anti-vax and anti-science movement with this recent pandemic. In hindsight, what could the government, healthcare providers, or medical educators, what could we have done differently?

Dr. Paul Offit
I think what happened is we didn’t have anything, right? All we had was a virus that could be transmitted asymptomatically. Anybody you passed in the street could be shedding a virus that could kill you. We didn’t have antivirals till October of 2020. We didn’t have monoclonal until November. We didn’t have vaccines until December. We had nothing other than avoid human-to-human contact. So that’s what we did. We closed businesses. We shuttered schools. We restricted travel. We isolated—and used—quarantine masks. And I think that alone was seen as massive government overreach. People didn’t like that.

They didn’t like that we closed schools. They didn’t like that we closed businesses. And then extending into 2021, once we had a vaccine, you had vaccine mandates. You couldn’t go to your favorite bar or sporting event or restaurant or place of worship unless you’d shown you had that card. And you just started to see pushback, all in the name of so-called medical freedom. That’s how we use the term freedom in this country. It’s often a way of saying that we don’t care about our neighbor because that’s what this was. I mean, the freedom to what? Freedom to catch and transmit a potentially fatal infection. Is that your right? I mean, if you choose not to get a tetanus vaccine, you get tetanus, no one’s going to catch tetanus from you. It’s not a contagious disease. This is a contagious disease. And there are millions of people in this country who can’t be vaccinated. They depend on those around them to protect them. Do you have any responsibility to them? And I think it was just seen as a massive government overreach.

Plus, I think we overpromised the vaccine a little bit. I think that those initial studies, which were really done over a period of three months, showed a high level of efficacy against even mild or moderate disease. But those were three months studies. Those people had just gotten their second dose. If over time as antibodies fade, you’re again going to be susceptible to mild disease. You should be protected against severe disease, which really only depends on memory, immunological memory. But mild disease, you could expect that six months later, protection against mild disease would fade. And it did. And I think people don’t wait. I mean, I’m mandated to get this vaccine. I got the vaccine like they told me. Now I’ve been in bed for a couple of days. I have a cough and fever, and I feel terrible, and I’ve been nauseated. And the government lied to me. That’s the way it was seen. And I feel sorry for Dr. Fauci who was sort of the face of all that. He sort of took all that upon himself. And I think he was viewed, at least by some, as being pedantic and condescending and sort of telling you what to do rather than necessarily explaining like, this is why we’re doing this. These are the issues at hand. I just think it was, we have paid an enormous price for that in an erosion in vaccines rates across the board. I think if there were to be another pandemic, we have seriously tied the hands of public health behind its back.

25:00
Dr. Jane Caldwell
So what should we be doing now to promote vaccines and vaccine safety?

Dr. Paul Offit
Just educate as much as we can passionately and compassionately and in as clear a way as possible that what vaccines are and what they aren’t and why they’re still important. I fear that the only way we’re going to kind of recognize their importance, frankly, is to see some of these diseases come back, which is sad because it’s always the most vulnerable among us, children who suffer that. And I think that’s what’s going to happen. I do hope I’m wrong. Normally I’m an optimist. I mean, I’m a Philadelphia Eagles fan, but, you know, I’m not so optimistic about this.

25:35
Dr. Jane Caldwell
Besides educational medical writing, you were involved in the documentary “Shot in the Arm”, and you have a Substack newsletter called “Beyond the Noise”. And by the way, we will link to those show notes for everyone. What else do you have coming in the future with medical education?

Dr. Paul Offit
Well, I’m actually working on another book, just the subtitle, which is “Who Can You Trust When Experts Give Bad Advice?” Because that’s sort of where we’re at now. I mean, you’re seeing a lot of people who are experts sort of bad advice and people who like Joseph Ladapo, an MD, PhD from Harvard who’s saying don’t get the mRNA vaccines because they’re contaminated with fragments of DNA that cause cancer, which is just utter nonsense. Those are the people that I worry about. It’s like Robert F. Kennedy Jr. worries me because it’s a platform and now he will have a bigger platform, but he’s a lawyer.

I mean, here are people who are trained, Dave Weldon, who will be head of the CDC, he’s a doctor who thinks MMR vaccine causes autism, even though data have shown that it doesn’t, or that thimerosal in vaccines cause autism, which it doesn’t. And he doesn’t trust the CDC, he doesn’t trust an agency he may be about to run. So it’s troubled times.

27:42
Dr. Jane Caldwell
What were you hoping I would ask you today?

Dr. Paul Offit
I think that was great. I think that’s what I was hoping you would ask me. What to do now in this troubled time, I think.

Dr. Jane Caldwell
Okay. All right, well, Dr. Offit, we appreciate your passion and thank you so much for joining us and providing a balanced look at polio vaccinations.

Dr. Paul Offit
Thank you.

Dr. Jane Caldwell
Thank you for listening to the On Medical Grounds podcast. OMG is your source for engaging relevant evidence-based medical information. We feature interviews with top experts along with complimentary teaching slides and continuing education credits on selected podcasts.

At OnMedicalGrounds.com and on our OMG app, we provide perks to all posted podcasts by linking content so you can drink in more if you so choose. Please be sure to click the subscribe button and be alerted when we post new content or download our app to get all of our podcasts, slides, and continuing education credits in one convenient location. If you enjoyed this podcast, please rate and review it and share it with your friends and colleagues.

This podcast is protected by copyright and may be freely used without modification for educational purposes. To find more information or to inquire about commercial use, please visit our website OnMedicalGrounds.com.

00:25
Dr. Jane Caldwell
Hi, this is Jane Caldwell. Welcome to the On Medical Grounds podcast, your source for engaging, relevant, evidence-based medical information. What you’ll be listening to today is part 2 of a three-part series on polio, a serious disease that was almost totally eradicated in my lifetime due to polio vaccination programs worldwide. We’ll be talking to polio survivors, healthcare providers who cared for polio victims, and a noted expert on polio and polio vaccines.

Today we’ll be speaking with Janice Flood Nichols. Janice Nichols was on the cutting edge of polio vaccination development. In 1954, she was one of over 1.8 million children from the United States, Canada, and Finland who participated in the Salk polio vaccine trial, the largest trial of its type in history.

These kids were dubbed the “polio pioneers.” Their study led to the successful production of a polio vaccination, which was licensed the following year. Prior to this study, Jan was diagnosed with polio as was her twin brother, Frankie. Her brother was lost to the disease while Jan survived. Ms. Nichols describes these events and more in her memoir, “Twin Voices, a Memoir of Polio, the Forgotten Killer.”

Jan has a bachelor’s degree in psychology from Seton Hill University and a master’s in medical rehabilitation counseling from the University of Pittsburgh. She has used her education and writing as part of her commitment to the eradication of polio and the promotion of vaccinations.

Hello Ms. Nichols. Thank you for joining us today.

Janice Nichols
Thank you.

02:17
Dr. Jane Caldwell
First of all, tell me about your twin brother, Frankie.

Janice Nichols
I think I’d like to tell you about our polio story, and you’ll learn about him to a certain extent just by that conversation. We were in first grade at the time, and it was fall 1953. Frankie was a typical little boy, super busy, super in love with especially baseball, but he had had a little cold, a head cold for a few days.

And Halloween was going to be that weekend and my parents wanted to make sure that he would be fine to go out Halloweening with all of our friends. So, my parents kept him home from school. And on the day before Halloween, Frankie developed a terrible time breathing. So, my parents rushed him to City Hospital for Communicable Diseases in Syracuse. He was given a spinal tap to determine whether he had polio or meningitis and he was immediately placed in an iron lung, which was a forebearer of today’s modern ventilators. They’re a cylindrical machine and a person’s body, except for their head, is encased in this machine. And by alternating air pressure, it does the work of paralyzed lungs.

By the next morning, they had confirmed a diagnosis of polio. Because Frankie was so gravely ill, the doctors decided to bring me to the hospital and give me multiple doses of gamma globulin. It was the only thing that they knew at that time that could sometimes prevent a case if someone was not yet infected or lighten a case if possible. So rather than getting just the one shot, I received multiple shots, up and down, both arms and both legs, and then the one in the buttocks as well.

And I was so weak, and they had to put me in a wheelchair and bring me to my father’s car. And the next night, at about 10:30 at night, Frankie died. He died on November 1st, 1953, which is All Saints Day in my faith. My family owned a funeral home in Syracuse, but they had requested permission to “wake” him in our own home. No one was ready to just turn Frankie over to anyone.

So, the county agreed, and Frankie was “waked” for two nights in our home. I insisted that I be present for everything. I had never been away from him, not even for a day, and I had to be with him up to the very, very end. And at night when the calling hours were over, they allowed me to spend just a little bit of time alone with Frankie in the room where his casket was held.

He loved baseball. So, at six years old, I figured, in heaven, he better have all his equipment. So, I actually put his ball bat and mitt under his little body. After the two days of waking, we had a funeral mass for him, which I attended. And then we all went to the cemetery to see his burial. That night, we went up to my maternal grandparents’ home. And I developed a terrible headache. I’ve never had a headache or anything like that. So, my parents called our pediatrician who came to our house and examined me. He asked me to take my chin and put it down to my chest. I couldn’t move at all. So, I was rushed off to the hospital. And for about the next four days, I remember nothing. Apparently, I had an extremely high temperature. The doctors could not tell my parents whether I was going to live or not.

But when I woke up, even though I couldn’t move, the only thing that scared me was hearing a cough from a little baby down the hall. We were in individual isolation rooms, glass isolation rooms. And I had just never heard a cough like that. And I asked my nurse what was wrong with the baby. And she told me that the baby had whooping cough. At six, I knew nothing about that disease. But I’ve spent the rest of my life wondering whether that little baby lived or died.

Later on, that same week, my mother suffered a miscarriage. In the end, 12 young children from our small suburb and one mother were admitted to the hospital. Two children died, my twin, or three children really, my twin Frankie almost immediately and two of my friends later on because of complications. Two children had temporary paralytic polio. I was one of those kids. Both of us grew up. We made really good recoveries until post-polio syndrome started interfering a little bit with our lives some 40 years later. So that’s my initial story, but it’s affected my life forever. It influenced what field I went into, and it’s influenced my long fight for over 20 years to finally eradicate this disease.

It’s a terrible, terrible virus, but it does not want to give up. But we’ve got people all over the world who are more determined on this virus to finally get rid of this disease. But we have to have children vaccinated around the world in order to pull this off.

07:56
Dr. Jane Caldwell
Janice, thank you for that. That was an incredible story and incredibly sad. So, this, of course, was before the development of the preventative vaccine for polio. How was polio viewed by families back then?

Janice Nichols
Well, we were just little kids, so we did not understand how terrified our parents were. But as an adult, I learned just how terrified they were. They were willing to do anything and everything imaginable to stop this disease. We were kids born after World War II. Our parents had all fought in World War II, and they felt that the United States could do anything and everything, including develop a vaccine that would stop this disease. So, when the vaccine trial took place, decisions in terms of what schools were going to be affected, which areas, was made at a school district level. They allowed me to be in the trial because they weren’t about to say no to my parents who had already lost one child, nearly lost me, and my mom had a miscarriage.

Today I would not be in the trial because we know more about double blind studies. We knew nothing about them then, but we were proud to be in the trial. And I don’t think our parents were overly afraid. They believed in science, and they wanted to do anything possible to stop this terrible virus. Just before the vaccine trial was rolled out, there was a columnist on the radio, his name was Walter Winchell, and he got on the radio and told parents that the United States government was stockpiling little white coffins for all the children who would die if they took the vaccine. About 150,000 children were pulled from the study, but thankfully most of us were not pulled.

And I’ve always wondered if some of those kids who were pulled, did they become victims or survivors of polio because they didn’t have the vaccine? We were proud to be a part of this whole thing. And they call us Polio Pioneers, telling us that we were not only helping our own generation, but we were doing something for all future generations of children. And to this day, when you meet a Polio Pioneer, we’re still speaking very proudly of our experience.

10:53
Dr. Jane Caldwell
That’s incredible. So where were the vaccines administered and how were you monitored? This is a really huge study. Did you go to a central place like a hospital?

Janice Nichols
No, we were administered the vaccine in our schools. And it was over 80% of all the kids in DeWitt.

10:54
Dr. Jane Caldwell
And then how were you monitored after?

Janice Nichols
We got three shots, okay? And then they began to make decisions about all kinds of things. One of which is they knew who got the vaccine and who didn’t get the vaccine. So, in the fall, parents were notified that their children had received the vaccine and would not need three more shots. If you were unfortunate and you just got a placebo, you got to have three more shots.

I received the actual vaccine. So, I did not need further shots. It took a year for the University of Michigan to actually go the thorough study to determine whether the vaccine was effective or not. We didn’t have big computers at that point. They were doing everything by hand, you know, the old-fashioned math kind of stuff. And it took them a year, but it was determined that the vaccine was effective. In some ways more effective. There are three polio types, and the vaccine did better with some types than others, but it was determined to be a good vaccine. So, in 1955, the vaccine was licensed and all over the country, Canada and Finland, children started getting the vaccine.

At first, the children most vulnerable, which were kids aged from about first, second and third grade. And then after that, they increased the vaccine coverage to older and younger children. We had a serious setback soon after the actual licensed vaccine came out. And they found that about 220,000 people had been exposed to a vaccine where not all of the killed virus had been killed. And a few people died.

There were a few people who became paralyzed, but they immediately stopped the study, determined exactly what went on, corrected everything, and they actually started the vaccine program up again.

13:34
Dr. Jane Caldwell
So, Janice, if I could stop you there, you’re talking about the Cutter incident, correct?

Janice Nichols
Yes. Yep. So, what’s amazing today, I don’t know if we’d have a polio vaccine because with all the litigation that takes place about anything and everything today, I think people would have started mass suits. People would have become so terrified that they would have just forgotten this vaccine. Fortunately, that didn’t happen back then. So, the program was reinstituted and things went on the way it should.

13:38
Dr. Jane Caldwell
So, Janice, as a child you had paralytic polio. Let’s talk about the post-polio syndrome that you mentioned earlier. Could you describe that please?

Janice Nichols
Right. Yeah, I think I’ll describe my paralyzed experience first. I had what was called temporary paralytic polio. And that’s defined for anyone who after a few months is still having trouble with all kinds of polio symptoms, which I certainly had. When we started the vaccine trial, I was just beginning to kind of walk again.

And I was a very fortunate child. My parents could afford to give me private physical therapy, which I had for years in one form or another. First with daily therapy, then re-enrolling in every physical activity imaginable. I started ballet classes when I was three. And my big goal in life was to put on those little ballet slippers again. So, I was dancing or kind of dancing, skating, you name it. I was doing everything imaginable. And I eventually became a very proficient dancer, skater, skier, I even cheered for a little while. So, I made a marvelous recovery. And then about 40 years later, all of a sudden, we all started having some weird symptoms and they took place very slowly.

So, at this point, I’m now 77 years old. I’m still walking on my own, but I’m walking much slower. I don’t have the same stamina I once had, but I just, I’m determined to go on and do everything I can. It’s a strange thing because you normally think, okay, if you have this, the more physical activity you have, the better you’ll be. Well, post-polio syndrome likes to put in an extra little wrinkle. And if you overexert yourself, then you’ll go backwards faster. So, you have a balance between staying active and yet not overtaxing your body.
And that’s the way we live.

I’m also fortunate that I’m married to an orthopedic surgeon who actually studied under one of the doctors that took care of me, one of the orthopedic surgeons. So, he’s always kept abreast of anything and everything that’s going on. And it’s just something that we live with. But I think most of us tend to be pretty spunky people. And we’re going to do our best to lead good, productive lives and fight back against this virus any way we can. And for me, it’s encouraging parents to vaccinate their kids.

16:30
Dr. Jane Caldwell
So, for the last part of this interview, I’d like it to be dedicated to your brother, Frankie. What would you say to Frankie if he were still alive today?

Janice Nichols
I’ve thought a lot about that question you asked, and I really can’t talk to him as someone who is alive today. All I can tell him is that I love him. I’ve missed him every day of my life, and he is the reason why I fight so hard to convince parents to vaccinate their children. No child in this world should have to ever, ever go through polio. No parent should ever have to face this.

But we have to believe in science and believe in what the experts are telling us, not what circulates the internet. So, my goal is to do something in his memory and honor, I guess. I love him. I am happy to see him someday, but I’ve got lots of stuff to still do down here. And I just hope that in my lifetime, we can finally say yes, we’ve finally eradicated this disease.

But I want to mention one other thing. Public health experts say that polio is a disease that’s just a plane flight or ship away from the United States. It’s kind of a stealth killer and crippler. Over 90% of people who contracted polio have no symptoms at all. So, you can be spreading the virus and have no idea that you’re spreading it, which makes it insidious. People can have the idea that nothing is going on. So, I just beg parents to please, please read and listen to factual information and not believe the naysayers because they are a very, very loud, and scary lobby in this country, and really around the world today.

18:30
Dr. Jane Caldwell
Jan, thank you so much for sharing your story with us today.

Janice Nichols
Thank you for having me.

Jane Caldwell
We’ve been speaking with Ms. Janice Nichols, author of “Twin Voices, A Memoir of Polio, The Forgotten Killer”. You can read a summary of her story and more than 100 personal accounts and case reports about diseases that vaccines can prevent on the website, Immunize.org.

And thank you for listening to the On Medical Grounds podcast. OMG is your source for engaging relevant, evidence-based medical information. We feature interviews with top experts along with complimentary teaching slides and continuing education credits on selected podcasts. At OnMedicalGrounds.com and on our OMG app, we provide perks to all posted podcasts by linking content so you can drink in more if you so choose.

Please be sure to click the subscribe button to be alerted when we post new content or download our app to get all of our podcasts, slides, and continuing education credits in one convenient location. If you enjoyed this podcast, please rate, and review it and share it with your friends and colleagues.

This podcast is protected by copyright and may be freely used without modification for educational purposes. To find more information or to inquire about commercial use, please visit our website OnMedicalGrounds.com.

00:18
Dr. Jane Caldwell
Hi, this is Jane Caldwell. Welcome to the On Medical Grounds podcast, your source for engaging, relevant, evidence-based medical information. What you’ll be listening to today is part three of a three-part series on polio, a serious disease that was almost totally eradicated in my lifetime due to polio vaccination programs worldwide. We’ll be talking to polio survivors, healthcare providers who have treated polio patients, and a noted expert on polio and polio vaccines.

Today we discuss how a virus changed history. Let me introduce our guest, Dr. William Schaffner. Dr. Schaffner is a Professor of Preventive Medicine and Infectious Diseases at the Vanderbilt University School of Medicine.

Early in his career, he was commissioned as an Epidemic Intelligence Service Officer with the CDC in Atlanta, where he investigated outbreaks of communicable diseases in the U.S. and internationally. Dr. Schaffner has worked extensively for the effective use of vaccines in both pediatric and adult populations and has been a member of numerous expert advisory committees that establish national vaccine policy.

Because he is committed to public communication about medicine, he is often invited to comment in local and national media and translate public health events and scientific research into accessible language to promote understanding.

Hello, Dr. Schaffner. Thank you for joining us today.

Dr. William Schaffner
Good to be with you, Jane.

01:56
Dr. Jane Caldwell
We’re interested in your experience and your personal stories about polio and polio vaccines. First of all, what attracted you to medicine as a profession?

Dr. William Schaffner
That was a long time ago, but I do remember being about eight years old and being so impressed with our family doctor coming to visit my brother and me when we became ill and visiting his offices on occasion. And somehow, I’m the first in my family tree. I decided at that very young age that I wanted to be a doctor and everything else has flowed from that.

02:37
Dr. Jane Caldwell
You graduated from Cornell University Medical College in 1962. Was polio still filling the children’s wards and hospitals when you were in school?

Dr. William Schaffner
Filling may be not accurate because before then we had started vaccination campaigns, fortunately. Yes, there were still children with acute onset of polio and obviously there were children in polio wards in iron lungs, which we’ll talk about a little later, who were receiving chronic care. So, polio was still with us when I was in medical school.

03:16
Dr. Jane Caldwell
The polio vaccine was created by Jonas Salk, and it became available in 1955. Did you receive the polio vaccine as a precaution for your occupational exposure?

Dr. William Schaffner
I actually was a Polio Pioneer. I was one, I received the vaccine I think when I was about 18 years of age, still in high school or early college. And I remember receiving a button that I pinned on my jacket that said I was a Polio Pioneer. And then later when the Sabin oral vaccine became available, we took that also.

Now that was just for general protection. And of course, back in that day, all healthcare providers received polio vaccine. Today, it’s no longer essential for being a healthcare provider because, as we’ll discuss, there’s no more polio.

04:16
Dr. Jane Caldwell
I didn’t know you were Polio Pioneer. What was that experience like?

Dr. William Schaffner
Well back then of course, all moms and dads were so excited to get a vaccine against polio because it was so intensely feared. And the lines were long when the vaccine first became available. Every child had been brought out. As you may recall, the March of Dimes was a nonprofit organization that was set up in order to fund research that developed the polio vaccine. And those of us who were kids took our little monies, and we would put them, our dimes literally and other coins, quarters, and nickels into slots in cardboard containers that were in stores around the community. These were all gathered together and those were the resources that funded the development of polio vaccine.

We were in effect crowdsourcing, as we would say today, the development of the vaccine. We children funded the development of the vaccine by putting our little resources in those slots. That’s how important we thought that was.

05:44
Dr. Jane Caldwell
Can you tell us about your most memorable encounter with a polio patient?

Dr. William Schaffner
Well, that was special. I can’t recall whether I was an infectious disease fellow or a young faculty member. I think I was a young faculty member. And that patient was a lady who had had polio in the past and was left with paralysis such that she still had difficulty breathing.

And so, she was confined to an iron lung for most, but not all of the day. She was admitted with an infectious illness that we quickly diagnosed and treated. But the most heartwarming thing about this lady is that she was married. And while I cared for her in that iron lung, while she was confined to the iron lung, it was evident that she was pregnant.

She was married. And this is one of the most heartwarming things that I recall of any patient. Here, she and her husband wanted to express their love and their intimacy with each other and to have a child, to have another generation out of their deep love for each other. And they managed to do that during those parts of the day while she was able to be outside of the iron lung, breathing for herself. This is one of the most affirmative experiences that I have had in medicine. And I understand that she had a healthy baby. I heard that later. So, this is a moving expression of human affection for each other and surmounting what would appear on the surface to be insurmountable difficulties and this commitment to each other and wanting to continue to have a family. Obviously 40 plus years later it still affects me deeply.

08:03
Dr. Jane Caldwell
Thank you for that memory. So, prior to your experience as a healthcare provider, did you know friends, family, or even classmates who were affected by polio?

Dr. William Schaffner
Sure, I mean, growing up polio was an illness that was clearly feared, and you knew kids in school who had had polio, some of whom recovered. My cousin had polio, he was left with just a little bit of residual paralysis, not enough for the Navy to detect it when he volunteered to join the Navy.

So, they took him in, so he recovered almost completely. Back in those days, polio was so feared, it was, it is an enterovirus, spreads more readily in the summer and the autumn. I couldn’t go swimming in community pools because although the virus was poorly understood by the population, there was a sense that if you gathered together with lots of other kids, you could pick up the virus and become infected so I couldn’t go swimming during many summers.

09:16
Dr. Jane Caldwell
So, could you please relate to us some of the symptoms and morbidities of polio?

Dr. William Schaffner
Well, polio is a virus that lives in the intestinal tract. And in order to create paralysis, it has to leave the intestinal tract, find the spinal cord and particular cells in the spinal cord, infect those. And these are the cells that direct our capacity. They send signals to our muscles to be able to move.

And if those particular cells are infected and destroyed, the signal cannot occur, and paralysis occurs. That’s how polio occurs. Now, polio is a very interesting virus because the vast number of individuals, back then often children, who were infected, had no symptoms at all. Only about 10 % of them developed an illness characterized by fever, fatigue, headache, loss of appetite, muscle aches and pains, and sore throat. This might last two or three days, and then they would get better completely. Only 1-2 % had this paralytic illness where the virus left the intestinal tract and then infected the spinal cord cells resulting in muscle spasms and respiratory difficulty. If the muscles to breathing were involved, you obviously couldn’t breathe for yourself because they were paralyzed. Hence the need for the iron lung, which of course was a machine devised to help you breathe.

11:05
Dr. Jane Caldwell
So, I’d wager that most of our listeners have never seen an iron lung, let alone worked around one. Could you describe the iron lung in more detail and how to train someone to use it?

Dr. William Schaffner
The iron lung was a wonderful technology of the past. We have better machines to help you breathe today, but back then if you were paralyzed you couldn’t breathe, and you probably had paralysis in your other limbs, also your arms and legs. So, you would be put into a tube. That tube had windows in it so we could look into your body.

It was secured around your neck. You probably had a tracheostomy, a breathing tube, to make it easier for the machine to work. You’re in the machine and the device actually acts like a bellows. It reduces the pressure in the tube, therefore expanding your chest and the good air comes in.

And then it reverses itself and, vroom, increases the pressure in the tube, pushing the bad air out. And that machine then goes in and out and in and out and breathes with you. Note, you’re paralyzed. You have no control over anything that happens. You’re totally dependent on, first of all, on an electric supply that keeps the machine going, and the personnel who can care for you.

It’s a profound psychological illness as well as a physical illness. And the people who cared for such patients were trained to care for patients psychologically as well as physically. And yes, that meant your bodily excretions, your fluid, your eating… all were within the control of the people who care for you. Fortunately, the initial inflammation that caused the paralysis often receded and people began to recover either completely or partially. And so, you could then withdraw people from care in the iron lungs.

13:39
Dr. Jane Caldwell
That’s an aspect of iron lung I didn’t know about, the psychological aspect.

You did mention in a previous interview that more than 20 years ago when the design for the Monroe Carell Jr. Children’s Hospital in Vanderbilt was first being considered, the planners didn’t have to make allowances for the treatment of children using iron lungs. How huge was that?

Dr. William Schaffner
Well, I often tell this story in the context of speaking to people who want to know about vaccines and the impact of vaccines. You see, our children’s hospital at Vanderbilt in Nashville, Tennessee was a center in the southeastern United States for the care of patients with poliomyelitis. We had a large ward devoted to patients in iron lungs.

And what I usually say to people is, I don’t mention the disease. I don’t describe the ward. But we had a big ward for disease for which patients were referred throughout the southeast. And then when we built our fancy, wonderful new children’s hospital, we didn’t include a ward for that disease. And then I would look out at the audience and say, why didn’t we do that?

We were a regional center for the care of these patients. What was the disease? And of course, the disease was polio. And the reason we didn’t have to put a new, I must admit I get emotional about this, a new polio ward in our fancy up-to-date children’s hospital was because there was no more polio. We vaccinated every child. The disease was gone. It was eliminated. And isn’t that wonderful?

15:34
Dr. Jane Caldwell
Yes, I’d have to agree with you.
So, polio can also have some long-term effects. Could you describe the post-polio syndrome?

Dr. William Schaffner
So, there are people who are left with residual paralysis. They can learn to function in society. But we have discovered that 20 to 30 years later, some of those individuals develop further muscle weakness and muscle pain and cramps. That’s the post-polio syndrome. And they have to get more physical therapy in order to learn how to function with this surprising but gradually diminished physical capacity. We don’t exactly know why that is. We don’t think it’s the virus still causing illness in the body. It may be that those nerves that are left somehow were impaired through, shall we say, overuse over 20 or 30 years and they’re now no longer as functional. So even 20 or 30 years later, the residual of polio has come upon us again and given us new patient care challenges.

16:54
Dr. Jane Caldwell
Very few healthcare providers today have seen a polio patient. What could you tell doctors and nurses about diagnosing for polio and caring for polio patients?

Dr. William Schaffner
I’ve talked a little bit about that before. And I guess my first response to that question is, yes, very few physicians and nurses are around today who’ve taken care of polio patients. And that’s marvelous. I love that deficit.

We’re now using polio vaccine, as you know, globally to try to actually eliminate polio, to eradicate it from the world. There are challenges there which we needn’t get into, but the risk of polio today is very, very low.

But just a quick anecdote, I have been part of training physicians along with the head nurse back on that polio ward, in caring for patients in the iron lung in the old days. And after these bright young people are well-trained and the nurse will end the training session with saying, are there any questions you have? And they say, no, no. And then she looks them right in the eye, opens up the iron lung and says, get in. And she makes them get in. She closes the machine, the lung turns on the bellows and says, now you know what it feels like to be a patient. Very impressive.

12:40
Dr. Jane Caldwell
Do you think non-medical exemptions from vaccinations should be allowed for healthcare workers?

Dr. William Schaffner
Well, speaking about all vaccinations, you know that polio is not an obligatory vaccine for healthcare workers because we don’t have polio, but there is an array of other vaccines. And my answer is generally for all children, I think there should be medical exemptions, but I’m of that group of people who thinks there should be no non-medical exemptions, no personal belief or religious exemptions. I know of no structured religion that has any concern with vaccines and religious leaders of all sorts have spoken on this. In order to eliminate illnesses, we’re going to have to all sign up and be vaccinated. Remember, there are those of us who are weaker brothers and sisters, who have immune systems that cannot respond to the vaccines or who have a medical reason not to get them. The way we protect our neighbors who are weaker than we are is for all of us, all of us to be protected and create a cocoon of protection around them. I’m unhesitating in saying we have that obligation to our more frail brothers and sisters.

21:16
Dr. Jane Caldwell
How should we tell parents about polio and other childhood vaccinations?

Dr. William Schaffner
That they’re gone but not forgotten. And the reason they’re gone here is because we’ve all been vaccinated. But they’re still out there in the world. And as measles, that most infectious of viruses, has demonstrated, when we have pockets of children in the United States who go unvaccinated, measles can be imported into the United States and then spread widely among them.

And measles is not a disease that’s trivial. Of the children, and this has been demonstrated in these measles outbreak, 10% of them have to be hospitalized. That’s not a good thing. Back in the day, and I surprise medical students when I tell them this, before we had vaccines in the United States, 400-500 children each year died of measles and its complications. They died. The number today is zero. The reason it’s zero is that every child is vaccinated. We must maintain that barrier of protection for all of the children in the United States. And we’ve eliminated disparities in that regard in the United States by vaccinating all of our children.

21:47
Dr. Jane Caldwell
Given your personal history with polio and other preventable diseases, what keeps you up at night?

Dr. William Schaffner
I’ve alluded to that, Jane. Vaccine hesitancy and skepticism and indeed the anti-vaccine movement, a lack of confidence in science. Some of this comes because we’ve had so much success. If the mother hasn’t experienced and doesn’t know about vaccine preventable diseases and the grandmother doesn’t know either, this kind of information usually comes down through the maternal side of the family. These vaccine preventable diseases are not respected or even feared, and therefore the vaccine isn’t valued enough.

We have to do better in educating children in school about vaccine preventable diseases and the benefits of vaccine. That’s another soapbox of mine. We need to enhance the health education about vaccine in middle and high schools in this country. But I guess an optimistic thing I would always end with is speak to your doctor. Have a conversation with your doctor. The doctor is there caring for you and your children day in and day out, year in and year out. You can have confidence in your doctor. Speak with them.

Dr. Jane Caldwell
Dr. Schaffner, thank you so much for joining us today.

Dr. William Schaffner
It’s been my great pleasure.

Dr. Jane Caldwell
And thank you for listening to the On Medical Grounds podcast. OMG is your source for engaging relevant, evidence-based medical information. We feature interviews with top experts, along with complimentary teaching slides and continuing education credits on selected podcasts. At OnMedicalGounds.com and on our OMG app, we provide perks to all posted podcasts by linking content so you can drink in more if you choose.

Please be sure to click the subscribe button to be alerted when we post new content or download our app to get all of our podcasts, slides, and continuing education credits in one convenient location. If you enjoyed this podcast, please rate, and review it and share it with your friends and colleagues.

This podcast is protected by copyright and may be freely used without modification for educational purposes. To find more information or to inquire about commercial use, please visit our website OnMedicalGrounds.com.