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A “Polio Warrior” Recounts Decades of Struggle Toward Eradication

Sixty years ago today, at about the time you’re reading this, church bells began to ring across the United States. Cars honked their horns. Reporters rushed to phones, and people ran to the corner to buy newspapers and into barbershops to listen to their radios.

It was not a holiday, or a war, that caused the tumult: It was a scientific result. At a conference in Michigan, researchers had announced the first successful vaccine against polio.

If it is difficult now to understand why that was so momentous, credit the vaccine announced that day, and another one revealed soon after. In the United States, polio killed or paralyzed thousands of children every summer. In 1952, the worst year on record, it attacked 58,000 American kids, closing pools and movie theaters, turning streets into ghost towns as families fled crowded cities for sparsely settled summer colonies where they imagined they would be more safe. Around the world, hundreds of thousands more every year were mowed down by it; in societies with few resources to treat the illness or support the disability that followed, they faced a lifetime of mistreatment and poverty.

The vaccine announcement came from an unprecedented partnership of researchers in multiple countries, led by Dr. Jonas Salk and funded by the National Foundation for Infantile Paralysis, the “March of Dimes.” The partners had tested the formula on more than 1.8 million children. In Ann Arbor, the head of the trial, Dr. Thomas Francis of the University of Michigan, declared the vaccine was “safe, effective and potent.” Vaccinations started within days.

Within a few decades, the injectable vaccine achieved by Salk, and a separate, oral formula developed a few years later by his rival Dr. Albert Sabin, would begin reducing polio’s toll. Today, after an international eradication campaign involving millions of both dollars and volunteers, polio persists in just a few countries—but in those countries, it has proved more stubborn and resilient than anyone expected.

The big actors in the Global Polio Eradication Initiative are the World Health Organization, the Centers for Disease Control and Prevention, and the Gates Foundation. But the foot soldiers for decades have been volunteers from the humanitarian organization Rotary International. Few people are left who remember the earliest days of the polio struggle, but one—John Sever, MD, PhD—knew both Salk and Sabin, and in 1979, proposed that Rotary take up the eradication task that their vaccines had made possible.

Dr. Sever, who is now 82, was chief of infectious diseases at the National Institutes of Health and now is vice-chairman of Rotary’s International PolioPlus Committee. He spoke to me from his home outside Washington, DC about the eradication campaign. (I have edited and condensed our conversation.)

Maryn McKenna: You came of age as a physician in the prime years of polio; the disease caused progressively larger outbreaks through the first half of the 20th century. Were you aware of it at the time?

John Sever: I was working on a PhD in microbiology and an MD at Northwestern Medical School in the 1950s, so I was aware, of course, of polio. My father had been a practicing physician in the Chicago area, and I had a cousin who had polio paralysis of her legs, so it was very much a personal experience as well as professional. I remember that parents with newborns could buy “polio insurance” against the possibility their child would develop polio, so they could pay for the cost of care. It was on everyone’s mind, that children would be paralyzed and have to be in “iron lungs,” or die.

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John Sever, MD, PhD. courtesy Rotary International.

So 1955 marked the great finding that Dr. Salk’s vaccine worked, the vaccine containing a killed virus. Dr. Sabin was working on a live-virus vaccine. There was strong debate about the killed vaccine versus the live: Would the killed vaccines produced good solid immunity, or would it be temporary? Would the live vaccine be safe and effective? In 1955, the feeling was that the killed vaccine could be accomplished faster. After that, the live vaccine was completed and this country licensed that vaccine, and because of ease of administration and efficacy switched to it.

MM: The vaccines were used immediately to hold the disease at bay—but there was not, at first, any sense that they could be used to make it go away forever. Do you remember when anyone first floated the concept of polio eradication?

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A Sabin vaccine dose being prepared, courtesy Wellcome Images.

JS: In the early 1960s I was attending a meeting in Miami, and my wife and I came down to breakfast, and Dr. Sabin invited us to sit with him. He was very excited because he had just learned of some work from Cuba. In the United States we were giving the vaccine individually to children as they got progressively older, a first dose, and then a second dose, and then a third dose. But in Cuba they gave everybody the vaccine over a couple of days, in a mass immunization, repeated twice a year. They did that for practical reasons: It avoided the problem of maintaining refrigeration, because they could bring it out and then use it up quickly. But what they found was that they not only immunized and protected children, they eradicated polio from the island.

Dr. Sabin wrote a number of papers emphasizing that this was a great advance; it went beyond the then-current situation of immunizing children, while having the disease continue in children that didn’t get immunized. He saw also that it could be conducted with an economical vaccine that could be administered by mouth—which was his, the Sabin, vaccine.

MM: How did that first inspiration expand into a global campaign?

JS: I was at the National Institutes of Health, and joined the local club of Rotary International because it was an organization that was committed to helping others. I moved up and became the district governor, which means you are responsible for about 60 or 70 local Rotary clubs, and all this time I continued to see Dr. Sabin, because in his retirement he had moved to NIH. He would come to my office frequently to talk.

In 1979 I got to meet the president of Rotary International, Clem Renouf, from Australia. He was interested in developing a new activity for Rotary that would involve the entire organization, and thought it ought to be a humanitarian project, perhaps hunger or immunization. He knew I was at NIH, so he asked my opinion of what we could do, and I wrote him: “If a single vaccine were to be selected, I would recommend poliomyelitis.” At the time, less than half the children in the world were receiving any vaccine.

At the time, there had just been the last cases of polio to occur in the United States,  and smallpox had just been declared to be eradicated. So people felt it was possible, that we could aim to eradicate polio. Clem took the idea to the board of Rotary, and they accepted it, and shortly afterward the legislative body that represents all Rotarians voted that we would make immunization for the eradication of polio our No. 1 priority throughout the world.

MM: It must have been exciting to see that inspiration become reality.

JS: Well, it was. It was a great opportunity, to be able to bring together medical knowledge with a group that was willing to make it happen.

We conducted our first program that same year, to immunize children in the Philippines. There was a strong Rotary presence there and one particular leader, an ophthalmologist, Dr. Sabino Santos. The government was interested, the health industry was interested and willing, but they could not afford the vaccine; they needed our support. So we took that as our first project, and immunized about six million children in the Philippines.

After that we worked particularly with the Pan American Health Organization, the World Health Organization’s deputy in this hemisphere, which wanted to move forward on immunization. At the WHO, thing were moving at a slow pace, and PAHO wanted to show that we could make a thrust forward. I remember Dr. Sabin going around in helicopters to immunization sites in the Dominican Republic, and then in Brazil; the countries were very supportive of polio eradication and immunization. As each moved forward, we were there to help.

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Unable to walk, a polio survivor crawls down an Indian street. Wen-Yan King (CC), on Flickr

MM: Because of that campaign, the Americas eradicated polio from the hemisphere, yes? Which proved to the rest of the world that this was a reasonable goal to pursue.

JS: You’re right. It was brought to the World Health Organization in 1988, with the idea, “Why can’t we do it worldwide?” But also, Rotary recognized the need for more support. We brought together key people including Dr. Sabin, and we decided that we needed about $120 million. We had never raised anything like that, but we said we would try to do it in three years, and in 1988 we announced that we raised $240 million, twice as much.

At the same time the WHO set a target to eradicate polio. They chose 2000, which was a little ambitious, and Rotary set a target of 2005. But there have been obstacles, different types in different places, that were not anticipated. Things would go smoothly and rapidly in one area, and then not in another. It was amazing that all of China got immunized, when you think of the population and the geography and logistics, but they did a superb job, and the whole Western Pacific reached eradication, and Europe too. But then in Latin America there was civil unrest, and we would have to work with the governments and combatants to have what we called “Days of Tranquility”: not stopping a war, but just peacefully interrupting it for three days, so we could go in and reach children.

MM: You witnessed the changes in thinking regarding the different vaccines. The Salk injectable was used at first; then the eradication program adopted the oral Sabin formula, because health care personnel were not needed to administer it. The Sabin had unexpected dangers though, in that its attenuated virus could in rare cases cause polio, and so the campaign is swinging back to the injectable again. What do you think of that evolution?

JS: The introduction of (injectable polio vaccine, IPV) is being managed very carefully, via routine childhood immunization programs, which are conducted through Gavi, the Vaccine Alliance. We’re still using (oral polio vaccine, OPV), but we’re adding IPV, and we hope that it will be added everywhere by the end of this year.

You do see occasional reversion of the virus in OPV, to a type of vaccine-associated virus, which can produce polio paralytic disease. Now it’s not frequent, but it does happen, and so using IPV will help protect against that. The eventual plan is to move completely to the killed vaccine, as we’ve done in the United States, and other countries, so that you continue to protect your population until you’re absolutely sure you don’t need to, but you’re also avoiding the possibility of producing vaccine associated polio.

MM: There have been outbreaks of vaccine-associated polio, such as in Nigeria in 2009, that must have been very discouraging. That outbreak followed several years in which polio vaccination was denounced by religious leaders, and vaccination rates dropped, making children there vulnerable and reseeding the disease in nearby countries. With the goal close, how can such setbacks be avoided?

JS: You have to get support at all levels, the top level of the government as well as the middle and lower levels, as well as religious leaders, at all levels, down to villages.  We’ve had to deal with opinions about the vaccine causing sterility or causing HIV, and those become formidable to work out. Setbacks are disheartening, but we have learned to deal with them. There are times, like now in Pakistan, with the difficulty of getting immunization into some areas, and with groups taking it to the point of killing immunization teams. It’s a major concern.

MM: Nigeria has not had a polio case in six months, but the disease is not considered beaten there, nor in Afghanistan or Pakistan. Those last two may represent the greatest challenge, because of political disputes and religious opposition. Are you hopeful the job can be finished? Or will they remain the last hold-outs that could reinfect the world?

JS: I believe that the challenge can be overcome. It is taking more time and effort, but it’s down to just a couple of countries. We could still have flare-ups spread from Pakistan or Afghanistan, or other areas that we have not recognized, but I think our commitment is to eradicate polio. I’m not going to put another date on it; 2018 has been mentioned,  and I certainly hope that it will be all completed by 2018, but if it isn’t, then it’ll be completed a little later.

We’re still working on it. But we’re close.

Addendum: I’ve been writing about the polio struggle since before the first eradication deadline of 2000—though not at Phenomena since I just joined here. For reporting from inside the eradication effort in India, look here, and for the campaign’s challenges, consult this archive of posts.