I am Thankful for Jonas Salk

To the general public, Pittsburgh is the land of sports superstars but to me it will always be the land of Dr. Jonas Salk. It was here that he developed the polio vaccine taming a virus that struck fear in the population. 

Reading the excellent new biography of Salk, Jonas Salk: A Life by Dr. Charlotte Jacobs, reinforced that conclusion. I have read several books about polio and the race for the vaccine but none focused exclusively on Dr. Salk. To me the strength of Dr. Jacobs' book is that it doesn't just end with the conquering of polio but spends much time on Dr. Salk's post-polio life. 

One might think that once he received the deserved acclaim from the development of the vaccine that all would be smooth-sailing for Dr. Salk. However, that wasn't totally the case. The trials and tribulations that Dr. Salk endured trying to establish and maintain the institution that still bears his name is a case in point.

The most intriguing part of the book is Dr. Salk's battle with HIV, which occurred in the last years of his life. At this time, Dr. Salk had closed his laboratory and was focused more on philosophy and the humanities than medicine per se. However, this man -- who believed he was destined to be a benefactor of humanity -- delved back into the field and developed an approach to a vaccine. As Dr. Jacobs writes, "When the desperate need for an AIDS vaccine became apparent, Salk found a raison d’être.”

The approach he favored was that of a therapeutic, as opposed to preventative, vaccine in which the vaccine would be administered to those already infected with HIV with the hope that it might boost immune responses to the virus. If successful, such a vaccine would provide a "functional cure" for HIV. Needless to say and not surprising, such an approach, with some modernization, is still alive.

I read biographies not just for their historical value, but for inspiration. In that vein, my favorite passage from the book is this (from the last pages):

“...he held strong convictions. Certain about the merit of the things he had done, the things he wanted to do, he rarely expressed self-doubt. Connected to this, he was unrelenting, repeating his view over and over, never seeming piqued or tired. Once he determined a course of action, he would not waver from it. His persistence exasperated those on the receiving end.”

As I write this on the eve of Thanksgiving -- a holiday that celebrates the abundance made possible by productivity -- I am thankful for Dr. Jonas Salk whose work to rid the world of polio not only saved countless lives and raised the standard of living of the entire race but provides inspiration.

Thank you Dr. Salk.

Taming Wild Polio Virus

There was much attention devoted to recent changes in the global polio eradication campaign when it was announced that vaccination against type 2 polio virus will cease in April 2016. This change was prompted by the eradication of this strain of the virus from the planet, leaving just type 1 and 3 left. However, the removal of type 2 polio vaccines is likely a response to other issues as well.

Polio eradication is currently being accomplished using the live Sabin oral polio vaccine which has the capacity to cause vaccine-derived paralysis in rare cases. These vaccine derived paralysis cases are almost always the result of the type 2 vaccine strain and with wild type 2 polio virus no longer a threat, the risk-benefit analysis of continued vaccination against type 2 has become altered.

Overall I think this is a good development and will make polio eradication more likely and the vaccine more palatable to the population who, because of the rarity of polio, may fear the risks of vaccine-derived paralysis.  

Wild polio has found its last refuge in just 2 countries -- Afghanistan and Pakistan -- while vaccine derived paralysis has been noted in several countries. So long as the live vaccine is used, the risk of vaccine-derived paralysis will be present.

However, a larger issue which lies behind the entire program, is the lumping of cases of vaccine derived paralysis with wild polio cases, a practice that has always struck me as problematic, especially given the use of the Sabin vaccine (which is considerably cheaper than the inactivated Salk vaccine) for which the risk of such cases will always be non-zero. 

If planetary eradication will only be declared once polio vaccine-derived cases are gone, the world will be waiting considerably longer. Eradication of wild polio virus is the real goal we should be focused on.

Medicine Before the Vaccine: A Review of Polio Wars

In an era before vaccination against polio--which has chased the paralytic form of the disease  from all but 2 countries--care for those afflicted with the dread disease was paramount. That care was severely hampered by a lack of understanding of all the facets of polio including that it is a gastrointestinal virus which causes paralysis only in rare cases. At that time bed rest, splints, and orthopedic surgical procedures were part of the routine care administered to a patient. 

To a person reading this in 2015, bed rest should sound like a foreign concept as anyone suffering with a paralytic condition caused by, for example, a stroke is basically overwrought with visits from physical medicine and rehabilitation physicians (physiatrists), physical therapists, and occupational therapists who work diligently with the patient in the hope of regaining function as well as learning to accommodate any permanent dysfunction.

It is hard to imagine it otherwise, but it was.

In Polio Wars: Sister Kenny and the Golden Age of American Medicine Yale University historian Naomi Rogers provides an exquisitely detailed and scholarly account of how an Australian bush nurse took America, in the decade before the Salk vaccine, by storm and crusaded to change how polio was treated and conceptualized in the face of fierce opposition by the medical establishment. At one time, she was the most admired woman in America and the subject of a Hollywood biopic. 

Reading the book one is immersed in the world of American medicine in the 1940s and 1950s where physicians held a special status that, I believe, has eroded into the Burger King Have-It-Your-Way style of medicine of today. Physicians forcefully debated, physicians voraciously read, and physicians meticulously thought. While life in such rarified air might be refreshing to read about for physicians, especially when they are today deluged by complaints from patients doggedly pursued by administrators who care little for whether a medical decision was correct or not, the downside was a recalcitrance by some to pursue therapeutic leads if their pedigree was lacking. Such was partially the situation with Elizabeth Kenny and her efforts to improve the care of polio patients. 

While Kenny, who may have lacked a full understanding of the pathophysiology of polio, clearly seems to have embellished and exaggerated the results of her work, which was centered on early mobilization, treatment of muscle spasm, and retraining of muscles (some of which had been advocated pre-Kenny) her intransigence was admirable and her battles with the well-connected and powerful instructive as well as instrumental to the professionalization of the field of physical therapy and highlighted the important role of physical medicine and rehabilitation physicians.

Jonas Salk: An Original Scorpion Team Member

Last night on the CBS show Scorpion one of Pittsburgh's most esteemed former residents was mentioned: Dr. Jonas Salk.  For those who don't know, Scorpion is a show about a team of geniuses that assists the Department of Homeland Security with special problem--a premise I find fascinating.

The context of the Jonas Salk mention was regarding the strategies needed to tackle difficult problems. Specifically, when Salk was solving the problem of the polio vaccine he battened down and thought through the problem and didn't just wish that things would go his way. This is the admonition to  never putting anything above the facts of reality, or as Ayn Rand succinctly put it, never put an "I wish" above an "it is"--something that physicians and scientists, especially, must never forget. 

Being from Pittsburgh, Jonas Salk has a special resonance with me. I have heard countless stories from people who knew or met him and I'm a bit jealous of their opportunity. Walking around Pittsburgh, being an odd person, I sometimes think about what it would be like to see him walking down the road, getting a slice of pizza, or other things that I do in Pittsburgh every day. In the book Splendid Solution: Jonas Salk and the Conquest of Polio--which I highly recommend--it details his almost ritual lunch at a now long gone Chinese restaurant where The Pittsburgh Press (also long gone) science reporter John Troan would try to get an indication of what was transpiring with the polio vaccine work that ultimately changed the face of this dread disease. 

One scene in particular really grips me. After the resounding success of the clinical trial of the vaccine was announced in Michigan, Dr. Salk returned to Pittsburgh and was greeted by throngs of people expressing their thanks for he and his team's achievement. His motorcade had a police escort. Imagining Dr. Salk receiving the fanfare almost exclusively reserved for the Pittsburgh Penguins, Pittsburgh Steelers, and the Pittsburgh Pirates is kind of exhilarating and I can almost experience the sense of justice and Pittsburgh pride that must have electrified the air on that day.

I am glad that Scorpion, a show whose theme I believe revolves around the crucial survival value of intelligence saw fit to pay homage to one of the real life examples that concretizes the veracity of its theme. 

How to Tame a Virus- A Review of *Paralyzed with Fear: The Story of Polio*

Polio is an infectious disease that holds a special allure for Pittsburghers. It was here that Jonas Salk conducted the research that led to his famous vaccine, forever changing the relationship between humans and this virus. I often imagine what it must have been like to witness Dr. Salk's triumphant return to Pittsburgh--police escort and all--after the vaccine was shown to be efficacious. Dr. Salk's achievement, however, is not something that stands alone; it is part of a pantheon of scientific advances (not the least of which includes Albert Sabin's version of the vaccine). 

There have been many books written about this virus, Jonas Salk, and other aspects of the fight to rid the world of this virus. One such book cost me a considerable amount of money (and is now available for $3.50). 

I recently completed one of the newer additions to this growing library: Gareth William's Paralyzed with Fear: The Story of Polio. 

I really enjoyed this book primarily because it provided a broad, historical, inductively-based scientific approach to the topic. Instead of providing a simple chronological listing of the landmark achievements that led to the control of polio, Dr. Williams employed an approach that places the reader on the trail of scientific inquiry that painstakingly led scientists, step-by-step (and down some unfortunate blind alleys), to higher rungs in the ladder of knowledge which culminated in Eckard Wimmer's synthesis--from scratch--of polio in 2002. 

Some highlights of the book include: a description of the well-known rivalry between Sabin and Salk (which included a particularly nasty bit of correspondence in which Sabin wrote to Salk that "love and kisses were being saved up" for him); DA Henderson's discovery of vaccine-associated paralytic polio (VAPP) linked to the Sabin vaccine in the 1960s; the anti-vaccine movement's opposition to the vaccine; a thorough discussion of the discredited hypothesis of the polio vaccine being the origin of HIV; speculation that FDR may have actually had Guillan-Barre Syndrome (not polio); the "fear campaign" designed to spur public concern in the US over this disease, which was never as big a threat to US public health as other diseases; and countless other anecdotes that make for good reading.

As of today polio eradication remains a daunting task with 89 cases occurring in 9 countries this year, 2 of which are new to the list from 2013. Nigeria, Afghanistan, and Pakistan are the 3 most important heads of this hydra that must be decapitated if eradication is to succeed. It remains to be seen whether this eradication will be successful but one thing is certain: the polio vaccine and the individuals who created it, or whose work led to its creation, have thoroughly destroyed the ability of this virus to wage war on mankind. It only remains for humans to allow the destruction to be total.