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Book Review

Poliovirus and poliomyelitis have a short history of only 200 years. Poliovirus has three types, is a small RNA enterovirus of 11 genes, and its genome was sequenced in 1981. Polio=grey and myelo=spinal cord: polio is inflammation of the grey matter of the spinal cord. Poliomyelitis occurs only in humans, chimps and gorillas. Poliomyelitis has been absent from the Western world for 50 years – today it is a problem only in Nigeria, Pakistan, and Afghanistan. World Polio Day took place recently (24 October).

But where was poliovirus prior to 1789, when the first case was described? Where will poliovirus be after 2020, when polio is eliminated (eradicated seems too strong a term) from the world?

While there is a large number of different strains, type 1 causes most epidemics and 80 per cent of paralysis. Type 2 is rare, fairly benign and causes 7 per cent paralysis. ‘Virus’ means ‘poison’. A single, small poliovirus can produce 10,000 progeny within six hours of invading and entering a cell. 

This book, written by Gareth Williams (author of Angel of Death on smallpox) is replete with facts and figures, well-illustrated, superbly annotated and referenced.  Williams traces 200 years of understanding and misunderstanding polio. The book is clearly written for a medical and scientific audience, with lots of unexplained medical terminology and some highfalutin neurophysiology.

The impact of polio has been well described by Patrick Cockburn in his book The Broken Boy, describing the last outbreak in Ireland in the 1950s. Philip Roth, in his novel Nemesis, dramatically describes the disintegration of a Jewish New Jersey community as a result of a polio epidemic in the 1940s.

The US reported 58,000 cases and nearly 3,000 deaths in 1952.

I am among a generation of doctors not to have seen a new clinical case. Polio instilled fear in communities for its ability to paralyse, to cause deformity and to suffocate children unto death. It struck healthy, well children. The overwhelming majority (95 per cent) of people with polio experience no symptoms, 3 per cent experience minor symptoms, 1 per cent contract meningitis and 0.1 to 1 per cent get paralysis. Mia Farrow, Joni Mitchell, and Johnny Weissmuller had polio. Itzhak Perlman, a wonderful violinist who I heard playing in Philadelphia, was paralysed by polio. Polio has been called ‘the crippler’. While polio was never as big a killer as measles, pertussis or tuberculosis, it induced fear and ‘polio hysteria’ during epidemics.

Polio virus is spread by personal contact and, being an enterovirus, is eliminated in the stools. Williams, in this well-organised book, goes through polio’s early history, the tortures inflicted on victims (being cared for by orthopaedic surgeons he identifies as one of them), Sister Kenny’s charlatanism, excessive isolation, prolonged bed-rest, splints, frames and procedures that often did more harm than good.

Physiotherapy and hydrotherapy helped, surgery usually not. Iron lungs supported some children through acute respiratory failure. For many, however, iron lungs were long-term, pre-morbid death tombs. We heard much (and rightly so) of Franklin D Roosevelt’s polio (though it probably was Guillain-Barre syndrome), because it led to the US President, who went to great extremes to hide his disability, being polio’s champion, establishing the National Foundation for Infantile Paralysis, better known as the March of Dimes (a wonderful resource for research and treatment).

Most of the advances in our appreciation, prevention, and elimination of polio came from the US. The kernel of this book is the battle between Jonas Salk (killed vaccine) and Albert Sabin (live attenuated vaccine) for the Nobel Prize and national/international acclaim. Who won? Salk got there first, but his success was mired by the Cutter incident, where some of his formalin-killed vaccine was in fact live, a possibility predicted by arch-rival Sabin. But Sabin’s vaccine was 100 per cent effective, very safe, easy, and innocuous to give and capable of giving intestinal and general immunity. A good story.

And so to today. Sabin’s vaccine has eradicated polio from Ireland since 1961. A few cases of vaccine-associated paralytic polio (VAPP) have caused some European countries to revert to the killed Salk vaccine. The last 30 years have seen the appearance in adults, long seemingly recovered from polio, of post-polio syndrome (PPS).

Taliban spokesmen (scientists all!) state that polio vaccine contains a poison developed in the West to sterilise Muslims. Several polio vaccinators have been shot in Pakistan. India has seen a dramatic drop in polio cases in the last decade. Williams started this text in 2011 in the hope that polio would be ‘conquered’ by the time he finished. The World Health Organisation (WHO) has missed several deadlines for polio eradication.

Credit to the US, whose energy, determination, organisation and untold millions of dimes led to a concerted effort to destroy poliomyelitis.  Congratulations to Williams — 300 pages of text, 30 pages of annotation, six pages of reference.   

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