Polio
Author: David M. Oshinsky

Overview

This enlightening book explores the history of a disease which the author said drew more attention, and struck more terror, in the mid- twentieth century although it was paradoxically ‘never the raging epidemic portrayed in the media’. As a historical document, the book traces the biography of polio from its earliest depictions in the writings of Hippocrates and Galen, through to its manifestations as ‘small clusters of infantile paralysis in Western Europe and the United States’ in the mid-1800’s, and to its eventual isolation by Karl Landsteiner in 1908. But at the heart of the book is the race to develop an effective vaccine for polio, a contest that pitched two contrasting giants of virology against each other in one of the most vicious rivalries in the history of medicine. And although the book detailed the clinical, academic and research dimensions of polio, it was the politics and the business of the disease that were its predominant focus, the narrative demonstrating how charitable organisations determined the course of events and elevated the status of polio above diseases such as influenza and smallpox which caused ‘great pandemics‘ (pages 4-5 and 9-11).

 

Synopsis

The book provided a detailed exploration of the biological properties and the clinical manifestations of polio. For example, it noted that there were ‘three distinct antigenic types of poliovirus, type I being the most common and virulent’, and that the virus ‘enters the body through the mouth, travels down the digestive tract, and is excreted in the stools‘. Although the virus only occasionally invades the central nervous system, the book stressed the serious consequences when this happens as it destroys motor neurons and causes ‘irreversible paralysis‘ and death ‘when the breathing muscles are immobilized’. The author narrated several heart-breaking examples to illustrate the gravity of severe polio, for example the story of Fred Snite, the wealthy man who contracted polio whilst on vacation in China; although he spent the rest of his life in an iron lung, the author recalled that he went on to get married, have three children, and ‘became a powerful voice for polio survivors’. The care of people with polio before the vaccine era also featured prominently, and the author illustrated this with the story of Sister Elizabeth Kenney, ‘the most popular, and controversial, physical therapist of that time’ who the author said ‘brought some humanity‘ to the care of polio victims. Although her unorthodox methods earned her the ire of ‘the medical establishment’, the author said she nevertheless garnered the popular support of the public (pages 8-9, 60-64 and 73-78).

In its dramatic rendition of the race to develop a polio vaccine, the book focused on the personalities that dominated the scientific enterprise. Just as the book provided detailed portraits of the enigmatic personalities at the heart of ‘the quest‘, it also noted that there were ‘ticklish moral questions‘ about the safety of their competing vaccines‘. For example, the book described Albert Sabin as a scientist who was ‘capable of doing elegant work in the laboratory’, and as a hard worker who stood out for his ‘nonstop schedule‘, and whose ‘work in polio, spanning twenty years, had been anything but a hurried pursuit‘. He however added that Sabin was ‘a rival with his own agenda’ who believed ‘polio research to be a zero-sum game‘ because ‘there was no room in his world for two successful vaccines’. Similarly, the book’s portrayal of Jonas Salk noted that ‘he excelled at almost everything in medical school’ and ‘showed tremendous skills as a clinician and surgeon’, but that he remained ‘an outsider‘ from ‘the tight, clubby world of virus research’. And in his characterisation of Hilary Koprowski, the third but less influential polio vaccine pioneer, the author depicted him as someone who ‘had many talents‘ and who ‘both inspired and intimidated people with his worldly charm, volcanic temper, and willingness to take risks‘, including testing live vaccines in children (pages 6, 95-110, 133-136, 141, 152, 168 and 242-249).

The book provided a detailed account of the research carried out by both Salk and Sabin, the two final rivals in the race to produce the vaccine. For example, it chronicled the large trial Salk undertook in 1954 to confirm the safety and efficacy of his killed vaccine against the three poliovirus types. Describing this as ‘the biggest public health experiment ever’, the author said it was ‘the biggest medical gamble in history’ in which ‘more than 600,000 children were vaccinated at least once’. The author also described how the successful outcome of the study, announced to great acclaim, transformed Salk into ‘a bonafide hero‘ to whom ‘gifts and honors poured in from a grateful nation’. Similarly, the book charted Sabin’s work which culminated in a similarly large-scale test of his live attenuated oral vaccine in Russia. With the ‘potential to wipe out polio completely’, the author described how its global adoption ensured that ‘the 1960s would belong to Albert Sabin the way the 1950s belonged to Salk’. However, even though his vaccine largely replaced Salk’s, the author said Sabin ‘would never be the cherished public figure that Jonas Salk was’, adding that ‘where Sabin had been a favorite of the academy, Salk was a favourite of the people‘ (pages 157-158, 167-171, 185-203, 214-215, 234-254, 261, 267 and 275).

The feud that festered between Salk and Sabin remains one of the most enduring in medical history, the author referring to it as ‘a rivalry that defined and dominated both careers, outlived both men, and continues to this day‘. The author described the feud as ‘a bitter, widening free-for-all in which ego, careerism, and principle would become hopelessly blurred’, and it illustrated this with how Sabin publicly positioned himself as the ‘anti-Salk‘ and launched a ‘withering assault upon his rival’s work’. The author explained that ‘there is still ongoing debate over which man produced the better vaccine and which vaccine should be used today’, noting that although the Sabin live oral vaccine has the widest usage, it also carries a risk of inducing polio – an observation that he said led to the reintroduction of the Salk vaccine in the United States in 1996. The book also profiled the other personalities who influenced the direction of polio research in America; an example was Simon Flexner, the first director of the Rockefeller Institute who put polio ‘near the top of the list’ of ‘diseases to be given priority’ although many of his erroneous concepts about the disease slowed progress towards the development of polio vaccines (pages 7, 15-18, 122-127, 178-179, 243, 273, 279 and 288).

The history of polio is intimately linked to its most famous victim, Franklin Roosevelt, the American president who contracted polio in 1921 during what the author said was ‘a terribly stressful time’ for him. The book argued that Roosevelt may have been particularly vulnerable to the disease because he had lived a ‘carefully sheltered‘ childhood in which he ‘avoided the common childhood illnesses’, a direct effect of the prevailing ‘antiseptic revolution‘. The author described how Roosevelt woke up ‘in pain, running a fever, and dragging his left leg’, and how his illness followed ‘a downward spiral‘ as ‘his pain grew worse, the fever lingered, and numbness spread to both legs’. Although it caused him to lose all movements ‘below his waist’, it is remarkable that polio did not truncate Roosevelt’s political career. Indeed, the book described how he skilfully used mobility aids to overcome his severe limitations; how he ‘became a master of concealment‘ in hiding his disability; and how he became ‘a potent symbol for polio victims and their families’ by changing the ‘public perceptions of the physically disabled’. The book also explored how he used his huge influence to ‘turn the conquest of polio into a national crusade’, doing this largely by unleashing massive fundraising initiatives through his National Foundation for Infantile Paralysis – ‘the largest voluntary health organization of all time’, and ‘the gold standard for private charities’. The narrative further demonstrated how the charity ’employed the latest techniques in advertising, fund raising, and motivational research to turn a horrific but relatively uncommon disease into the most feared affliction of its time’ (pages 5, 24-35, 41-45, 53, 67-68 and 86-90).

Opinion

This is a detailed account of an old virus which continues to plague the world. It is also a story of the science that brought it to heel. With a comprehensive account of the researchers who competed to develop effective polio vaccines, the book is as much an inspiring account of scientific breakthrough, as it is a human story of rivalries and petty conflicts. The book’s account also highlighted the advantages and perils of the collaboration of research with politics and philanthropy. Although perhaps disproportionately focused on the rivalries of the story, the book’s coverage is extensive in its portrayal of the business of charitable organisations and the political side of medical research.

Overall assessment

Polio remains a public health hazard in many parts of the world, ever-threatening to break through the cordon that the vaccines this book reviews have put around it. Understanding its history, and the steps that ensured its defeat, is as important today as in the last century. The book explores the important intersection of healthcare with politics and voluntary organisations, and it highlights the delicate balance that is required for this relationship to result in meaningful clinical benefit. With its detailed commentary on the funding of health research and the determinants of health policy, the contents of the book are relevant today and I recommend it to all doctors.

Book details

Publisher, Place, Year: Oxford University Press, Oxford, 2005
Number of chapters: 16
Number of pages: 342
ISBN: 978-0-19-530714-6
Star rating: 5
Price: £30.16

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