by David Isaacs
When she returned to Australia she found that a royal commission had accepted the opinion of Queensland doctors who condemned the Kenny method. Yet the Superintendent of Brisbane General Hospital, ignoring both the doctors and the royal commission, gave Sister Kenny her own ward so that she could continue to treat patients.
In 1940, the Queensland Government, more impressed by her results than the report, paid Sister Kenny’s fare to the United States to visit the Mayo Clinic in Rochester, Minnesota. Six Brisbane doctors were sufficiently impressed by Sister Kenny to write letters of recommendation, which she took with her.
The United States doctors were also dubious about the language Sister Kenny used to describe how polio caused disability, but three orthopaedic surgeons arranged for her to treat some patients in Minneapolis General Hospital and her excellent results soon convinced the doubters. The patients improved and went home more quickly than those not treated using the Kenny method.
The United States became enamoured of this tall, imposing Australian woman with white hair, who would speak gently to a child with polio one minute and berate a doctor ferociously the next. In Chicago she met Dr Morris Fishbein, editor of the Journal of the American Medical Association, who said, ‘She came in wearing that hat that made her look like Admiral Nelson. She looked like a screwball.’ In 1942 the Sister Kenny Institute was opened in Minneapolis, the first of a number of Kenny clinics in the United States. A year later Sister Kenny published her autobiography And They Shall Walk. The story of her remarkable contribution was told in a feature film made in 1946 called Sister Kenny, in which she was played by Rosalind Russell. When Kenny attended the premiere in New York, a crowd of 20,000 fans broke down the barriers in their efforts to get close to her.
By 1947, the Kenny method had become so popular in the United States that 10,000 polio splints were sold for scrap metal. The Kenny method was also widely adopted in Central and South America, particularly Costa Rica and Argentina.
Eleanor Roosevelt was the most admired woman in the United States for 20 years according to Gallup polls. In 1952, however, she was displaced by Sister Elizabeth Kenny. The people of America even raised funds to buy her a prayer book that had belonged to Florence Nightingale.
Although she was revered in the United States, Kenny remained a controversial figure in Australia, where few people have ever heard of her. She never married, but in 1926 she answered an advertisement in the newspaper to adopt seven-year-old Mary Stewart (who came from a destitute Brisbane family), thus becoming the first ever single Australian woman permitted to adopt a child.
Kenny took Mary with her to the United States. Mary was devoted to her adoptive mother and said she saved her life. Mary herself became a Kenny nurse. Sister Kenny developed Parkinson’s disease, retired to Toowoomba in 1951 and died in 1952.
In her heyday, she must have been a nightmare for the doctors she confronted, but she made more of a difference in the treatment of polio than all of them put together – so much so that the Kenny method became the foundation of modern physiotherapy.
The first vaccines against polio
Although much progress was made by Sister Kenny and others in treating polio victims, prevention was always going to be preferable, and a vaccine was sorely needed.
The story of polio vaccines is the story of two competing approaches, and of a great rivalry between two great men.
The first possible approach to making a polio vaccine was to produce attenuated poliovirus (like Pasteur’s attenuated rabies virus) that could be given orally. The alternative was to kill the virus, which would make a safer vaccine that would be less likely to cause polio accidentally. But then the vaccine would need to be injected, as a killed vaccine cannot be absorbed from the gut.
Albert Sabin moved to New Jersey in the United States from Poland with his family in 1920, aged 15, to escape the vicious pogroms being waged against the Jewish community. He was already engaged in polio research when Jonas Salk was finishing high school. Eight years younger, Salk was also Jewish, the eldest son of a Russian immigrant family which had likewise fled pogroms. His uneducated parents had worked tirelessly to send him to one of the finest high schools in New York.
While Salk was still training in virology research, the two men met at a polio conference in 1948. At one point, Salk asked Sabin whether an alternative method for mapping strains of polio virus could be found.
Sabin was scathing: ‘Dr Salk, you should know better than to ask a question like that.’
Salk never forgave Sabin for putting him down so publically, and later said it was like ‘being kicked in the teeth . . . I could feel the resistance and hostility and the disapproval. I never attended a single one of those meetings afterward without that same feeling.’
Jonas Salk and Albert Sabin would compete fiercely and uncompromisingly for the rest of their lives. (Given their similar backgrounds, perhaps it was a form of sibling rivalry.) Salk worked to develop a ‘killed vaccine’, or inactivated polio vaccine (IPV), which had to be injected, whereas Sabin persisted with a ‘live vaccine’, using attenuated poliovirus that could be given by mouth, hence it was known as oral polio vaccine (OPV). Each was convinced his method was the best way to make a vaccine and neither would ever contemplate compromise or collaboration.
Salk’s vaccine was the first to be tested on live subjects. Initially he tested it successfully on laboratory animals. Then in 1952 he injected 43 children at a ‘home for crippled children’, followed a few weeks later by children at a school for the ‘retarded and feeble-minded’. Following this, Salk inoculated his wife and three sons with his vaccine.
Polio vaccine was at a critical point. Salk wanted to immunise people with his IPV to prevent cases of polio, but Sabin wanted the country to wait for OPV, which was still in development. Salk’s critics accused him of being arrogant and glory-seeking.
In 1954, researchers in the United States, Canada and Finland conducted placebo-controlled field trials of IPV. Critics of the American trial said it was far too expensive, but FDR’s March of Dimes funded the program. This became a huge bone of contention with Albert Sabin, who complained long and loud about favouritism.
The spectre of paralytic polio was so frightening that parents were desperate for their children to be part of the trial, and the authorities had to turn away many thousands who wanted to participate. The children in the trial were called Polio Pioneers and were given a special commemorative card: 420,000 children were injected with IPV and 200,000 control children with an inactive placebo. The trial was blind: neither the children’s parents nor the doctors knew who had received which.
The eagerly anticipated results were announced at the University of Michigan at 10.20 am on 12 April 1955, the 10th anniversary of President Roosevelt’s death. (In fact the results were already known: the report had been written four days earlier.)
There was an audience of 500 present in the auditorium, including over 100 reporters and 16 newsreel cameras, and more than 50,000 doctors were waiting for the result. All over the country, people tuned their radios and listened with bated breath. The radio program Voice of America was set to transmit the results to Europe. Criminal trials paused to hear the news.
When a press release was issued, there was pandemonium. ‘It works, it works!’ shouted the reporters. They all tried to get their stories out at once. One climbed out of a window and took his fixed-line phone onto the roof so his message could be heard.
Department stores broadcast the news of the successful vaccine trial on speakers that had been set up specially. People danced in the streets in celebration. Church bells rang, sirens blasted.
More IPV was rapidly produced and the vaccine was licensed in the United States in 1955 with great fanfare. Elvis Presley was photographed receiving the vaccine in order to promote teenage immunisation.
But disaster was not far away. Two weeks after the launch, in April 1955, an infant was admitted to a Chicago hospital with flaccid paralysis of both le
gs. It was the first case in what came to be called the Cutter Incident, when more than 200,000 children were given a faulty vaccine, 40,000 of whom developed polio and 10 of whom died. (I discuss the incident in detail in Chapter 11.)
Within a month the first mass vaccination program against polio had stalled. This catastrophe at least had the benefit of stimulating the government to introduce strict regulations about vaccine manufacture. IPV was reintroduced after its safety had been assured, but not surprisingly people were hesitant and uptake was not at first as vigorous as previously.
Polio was a serious public health problem in the USSR, and in 1956 a delegation of Soviet scientists came to the United States to consult Jonas Salk on how to produce his vaccine. Albert Sabin seized the opportunity to invite the scientists to visit him in his laboratory at the University of Cincinnati, and he was rewarded with an invitation to go to the Soviet Union. Salk was also invited to visit, since Soviet scientists were having problems maintaining consistent efficacy of the Salk vaccine, but he decided not to accept.
Sabin spent a month in the USSR, and the Soviet scientists asked him to send them samples of his vaccine. On his return to America, Sabin asked the State Department for permission. The State Department approved the request, despite objections from the United States Defense Department, which was concerned that the live vaccine virus might be used for biological warfare.
The Soviet Union decided to buy Sabin’s OPV, and in 1959 used it to immunise 10 million children. The results were so encouraging that the Soviet Health Ministry gave it to everyone under 20 years of age, so that 77 million people received OPV – far more than were given IPV during the trial of Salk’s vaccine in the United States.
The Sabin OPV vaccine was released in the United States in 1961. The advantages of OPV are that it is much cheaper, it can be taken orally as drops (or in those days on a sugar lump), and it spreads from a baby’s faeces to other members of the family, which immunises them (and shows we are nowhere near as clean as we think). The disadvantage (as mentioned before) is that OPV can become virulent and cause vaccine-associated paralytic poliomyelitis (VAPP), but that occurs only extraordinarily rarely: 1 case in every 2.5 million doses of OPV.
Although IPV had reduced the incidence of polio in the United States from 135 cases per million population in 1955 to 26 per million in 1961, OPV rapidly took over from IPV in the United States. The annual number of American cases of paralytic polio fell from about 20,000 in the 1950s to 2525 in 1960 and 61 in 1965.
Salk never accepted that immunising the population with OPV was a wise decision. In 1973 he wrote an opinion piece for the New York Times claiming that OPV was unsafe and advocating that the United States revert to using IPV.
It would be 24 years before the United States Government agreed that IPV should replace OPV in order to avoid cases of VAPP. Initially, in 1997, IPV was just used for the first dose of polio vaccine and OPV for all subsequent doses given in the United States, but since 2000, Jonas Salk’s IPV has been used exclusively. In poorer countries, though, Sabin’s OPV is generally preferred to IPV. As mentioned, OPV is a fraction of the price and can be given more easily; it also spreads to unimmunised relatives.
Although many pharmaceutical companies begged him to do so, Sabin refused to patent his vaccine. Albert Sabin could be grumpy and irritable but he was a highly ethical man. He believed polio vaccine should be available to all children, no matter how poor. He lived off his salary as a professor and never made a cent from his discovery.
The fame that came with polio vaccine took its toll on Jonas Salk. His wife, Donna, never came to terms with the effects that the publicity had on their relationship, and they divorced in 1968. Salk remarried two years later, to the artist Françoise Gilot (the mother of two children by Pablo Picasso). He spent his later years fighting for peace. He described war as the ‘cancer of the world’ and travelled the globe meeting leaders to call for ways to avoid war.
Salk and Sabin were American heroes and received many honours, though, perhaps surprisingly, not the Nobel Prize. Both OPV and IPV proved vital in combating one of humanity’s most malignant infections, but ultimately perhaps it was their competitive insistence that their own vaccine was the only worthy option that deprived them of this honour. Maybe the Nobel Committee was worried they would squabble on the world stage.
‘Polio endgame’
By the early 1980s, experts began to contemplate the possibility of global eradication of polio. The WHO’s 1975 Expanded Programme on Immunization had increased world coverage, but there was still a long way to go.
Polio shares most of the characteristics that made it possible to eradicate smallpox. However, there are differences that make polio more difficult to eradicate. The symptoms of polio are highly variable and the diagnosis is rarely obvious at first. Most people transmitting polio are asymptomatic, so they cannot be identified. The poliovirus can exist for weeks or months under certain circumstances such as in untreated sewage, acting as a potential source of infection. There are also three strains of poliomyelitis – types 1, 2 and 3 – which all needed to be included in polio vaccines. For all these reasons, many experts thought poliomyelitis would never be eradicated. The WHO set out to prove them wrong.
The WHO introduced the Global Polio Eradication Initiative (GPEI) in 1988, with the aim of eradicating polio by the year 2000. Polio was endemic in 125 countries. In 1988, 350,000 cases of polio were reported globally – 1000 a day. There were four ‘pillars’ to the GPEI: better routine delivery of OPV; mass vaccination campaigns in countries or regions with high polio activity; better surveillance and testing of cases; and mop-up vaccination campaigns following any confirmed cases.
Early progress was impressive, although the target of global eradication by the year 2000 proved over-ambitious. Nevertheless, the number of countries where polio was endemic fell from 125 in 1988 to just 10 by 2001. The Americas were certified polio-free in 1994, the Western Pacific in 2000 and Europe in 2002. Type 2 poliovirus was eradicated from the world in 1999 and has not reappeared.
Progress in eradicating polio in Africa was initially slow. In 1990 there were some 4000 cases in Africa, by 1993 still 1000 in 34 countries. Football (soccer) is the most popular sport in Africa, and the WHO decided to initiate a campaign that pictured a soccer ball and had the theme ‘Kick Polio Out of Africa’. The campaign was launched by Nelson Mandela on 2 August 1996. His opening words were: ‘Africa is renowned for its beauty, its rich natural heritage and prolific resources – but equally, the image of its suffering children haunts the conscience of our continent and the world.’
By 2000 polio was circulating regularly in only three African countries: Egypt, Niger and Nigeria. The activity of the extremist group Boko Haram in northern Nigeria not only meant that polio persisted in that country, but also that it was occasionally reintroduced into other African countries such as Mali.
In 2010, to coincide with the 2010 Soccer World Cup in South Africa, Rotary launched a campaign targeting the 23 African countries where polio was still a threat. Bishop Desmond Tutu was one of several leading African figures who signed a soccer ball that was taken around and exhibited in the target countries. Children were encouraged to find Bishop Tutu’s signature on the ball.
Nigeria reported no cases of polio in 2015, four cases in 2016, and none since. Polio is about to be kicked out of Africa forever.
India has also proved a particular challenge. From the 1970s until the early 1990s there were 200,000 to 400,000 new cases there each year. Between 500 and 1000 children were paralysed by polio every day. By 1990, when 80% of the population had received three doses of OPV, the incidence was beginning to fall.
In 1995, India held its first National Immunization Day, when an astonishing 8 million children received oral polio vaccine at fixed booths around the country. From 2004, 10 of these ‘pulse polio campaigns’ were conducted every year, and virtually every child in India was tracked down and vaccinated.
In 19
90, there had been over 3000 new cases of polio in New Delhi alone. In 2009 almost half the new cases of polio in the world were still occurring in India, and eradication seemed a distant if not impossible goal. There were pockets of persistent infection, notably among children in poor, isolated provinces like Uttar Pradesh. Polio workers tried to reach these children by going house to house. In 2011, after using over a million vaccinators to reach remote areas, polio was eliminated from the whole of India. The last known victim was 18-month-old Rukhsar Khatoon from West Bengal. As Bill Gates said without hyperbole: ‘India’s achievement is one of the most impressive accomplishments in global health, ever.’
The crippling nature of polio and the drama of its eradication is illustrated by the story of Dr Mathew Varghese, whom Bill Gates visited in his hospital. Dr Varghese is an orthopaedic surgeon who for years ran the only dedicated polio ward in India, at St Stephen’s Hospital in New Delhi. The ward was supported financially by Rotary. Dr Varghese accepted every patient who came to see him, whether or not they could afford to pay for treatment. He performed surgery on afflicted children who could only crawl, enabling them to stand, and later to walk using braces or callipers. Dr Varghese treated children with one leg shortened from polio using leg-lengthening surgery, often allowing them to discard crutches and walk unaided. When polio was eliminated, Dr Varghese was thrilled to be able to close his polio ward.
Another polio hero was the late Brazilian epidemiologist Ciro de Quadros (1940–2014), who was Director of PAHO, the Pan American Health Organization. From 1985, de Quadros sent teams of polio workers to the most remote and war-ravaged regions of Latin America. His health workers recruited local volunteers and organised mass immunisations of children under five to coincide with local religious festivals. In war-torn El Salvador and Guatemala they negotiated ‘tranquillity days’, 24-hour ceasefires between rebel and government forces, to allow health workers to immunise children. They could not persuade the Shining Path guerrillas in Peru to cooperate, so they worked around the rebel-held areas and went back to mop up when the battlelines shifted. The last reported case of polio in Latin America was in Pichinaki, Peru, in 1991.