historical stuff by Gareth Millward
13 May 1988 – Geneva
Poliomyelitis is, sadly, still with us. But since 1988, global action on the disease has reduced the number of cases from an estimated 350,000 to just 445 in 2013.1 This is pretty remarkable for a disease that only reached epidemic proportions in the twentieth century, and with a vaccine that was developed as recently as the 1950s. Given my own research interests in the history of polio and vaccination, the Global Polio Eradication Initiative (GPEI) is the fourth entry in the 30-for-30 series.
The Forty-first World Health Assembly… declares the commitment of WHO [the World Health Organization] to the global eradication of poliomyelitis by the year 2000.
The GPEI may have missed this ambitious goal, but it was not for want of trying. The number of confirmed cases of poliomyelitis dropped significantly over the 1990s.2 The last bastions of the disease have, however, proved difficult to break down due to a combination of economic, political and medical factors.
Polio is, in many ways, a disease whose importance as risen alongside modern biomedicine. Though diseases which may be today thought of as “polio” were recorded in Ancient Egypt, proper classification of its causes, effects and treatment are definitely modern in origin. It was “discovered” through the works of Karl Medin and Jakob Heine over the mid-to-late nineteenth century. The virus responsible was only isolated in 1909.3
The first outbreaks occurred in Western Europe and the United States at the dawn of the twentieth century. Unlike infectious diseases such as tuberculosis or cholera, which were largely attributed to poverty and poor sanitation, polio seemed to affect everyone equally. There was also no cure, and so wealthier patients were not protected from their usual isolation from the vectors of disease or ability to pay for the best treatment. Indeed, there was strong evidence that the greater the level of sanitation in a region, the more likely it was to succumb to an epidemic. The first outbreak of epidemic proportions hit Britain in 1947, and by the early 1950s the Western World had mobilised its efforts to find some sort of medical protection against the poliovirus.
This may seem a very cynical interpretation of the history of polio, but there is no doubt that the battle against the disease was given a massive boost by powerful patrons with a personal interest. Franklin D. Roosevelt, President of the United States and polio survivor, founded the National Foundation for Infantile Paralysis. “The March of Dimes”, a fundraising campaign, attracted support from across the United States, fueled by “celebrity endorsements” from the likes of Lucile Ball and Louis Armstrong. Much of this money focused on medical research into the causes and prevention of polio.
That came to fruition in 1955 when Jonas Salk announced successful trials of a new intravenous poliomyelitis vaccination (IPV).4 It was quickly rolled out across the United States, and similar versions were used around the world. His rival, Albert Sabin, produced an oral polio vaccine (OPV) which was eventually adopted as a safer and more effective method. For children of my age, the foul-tasting drops on a jelly baby formed our memories of going to see the doctor.
The story of Salk vs Sabin is fascinating in its own right, and something I may cover at a later date.5 For now, however, all we need to know is that despite the overwhelming success of various vaccination programmes (polio has been nigh-on eradicated in the West since the late 1970s), scientific consensus is never enough to convince people to accept vaccination into their lives.
The Cutter Incident of 1955, for example, almost killed IPV before it had even begun. The Cutter Laboratories in California produced a batch of Salk’s vaccine with live poliovirus, not the inactivated version required to avoid infecting the patient. Hundreds of children caught the disease directly from the vaccine. Salk vehemently protested that the problem was with the manufacturer, not the design, and he was proven right. But the planned vaccination programme in Britain was delayed while the Medical Research Council and Ministry of Health debated on how to proceed. The British decided to make their own, despite being completely incapable of producing enough of the vaccine to inoculate the number of children who had been signed up for the programme. When they did cave to demand and began to import Salk’s vaccine, they gave parents the option to opt out. The MRC advised:
This country has an unblemished record and it is strongly felt in some medical quarters that it would be deplorable to run any risk of an accident such as might jeopardise public confidence, not only in the particular vaccine, but in preventive inoculation and vaccination in general.6
Cutter had shown that vaccination was not without its risks – and until the MRC was certain about its safety, the known risk of wild poliovirus was preferred to the unknown risk of Salk’s new invention.
Of course, by the 1980s manufacturing techniques had improved dramatically. New strains of the vaccine had been produced, and the new OPV was not only safer but easier to administer. With WHO backing, many countries adopted polio vaccination, and rates fell dramatically. Why, then, did progress stall in the early 2000s?
There were practical concerns, to be sure. Since there is an unhelpful relationship between sanitation and polio, vaccination is one of the very few public health measures that can have a lasting impact on the disease. (For instance, hygiene and quarantine were used in conjunction with smallpox vaccines to eradicate that particular disease.) Very remote rural regions were hard to access. As were war zones. Refrigeration is also a problem in places without electricity in sub-tropical climates. But there was a growing political opposition to vaccination too. Some of this was due to a post-colonial backlash against white doctors “experimenting” with black bodies. Other legitimate concerns from locals were fanned by groups with a political interest in driving out foreign observation. Attacks on aid workers in Pakistan and Afghanistan, for example, mean that this area is one of the very few where polio remains endemic.
It didn’t help that the Central Intelligence Agency was found to be using vaccination programmes to spy on remote populations.7 In the same way that Cutter and incidents like it have always been used by anti-vaccination campaigners who argue – against all epidemiological evidence – that vaccination is unsafe compared to a perceived “natural immunity”.8 Despite these setbacks, however, India was declared polio-free in 2014. The number of recorded cases has fallen from around 3,000 in the year 2000 to just 445 in 2013. The year for global eradication keeps being pushed back, but I hope that by the time I’m 40 the job will be done.