Polio’s Precarious Future A Review of Polio: The Odyssey of Eradication and an Interview with Dr. T. Jacob John

Abstract

Dateline 1957. At Brentwood Elementary School, I gravely receive Jonas Salk’s miracle shots, today known as inactivated polio vaccine (IPV). Five years later, at Paul Revere Junior High, I crunch sugar cubes dotted with pink along with other Angelenos who, between 1962 and 1963, collectively ingest 7.5 million doses of Albert Sabin’s oral polio vaccine (OPV). By now, the upside is clearer. With my own eyes, I have seenchildrenwearing awkward legbraces and readabout iron lungs. Soon after my birth, the latter, boiler-like contraptions filled entire wards of Los Angeles County-USC hospital during my city’s last, great polio epidemic. At the same time, the sciencebarely penetratedmybrain. Itwas not until the early 1970s that I fully grasped that OPV—a product containing liveattenuatedpoliovirus types1,2,and3—proliferated in thegut.Asa result, ourmedical schoolprofessorsproclaimed, OPV not only provided long-term humoral immunity against the paralytic disease but quickly induced short-term intestinal immunity to polio! And all for a fraction of IPV’s cost! Last but not least, in unhygienic settings beyond our borders, the fecal–oral spread of OPV serendipitously protected even more children and adults who would otherwise fail to receive the vaccine. So, it was really no surprise when, in 1988, public health leaders energized by the previous decade’s success against smallpox embraced OPV as the tool by which the world would evict yet another devastating scourge. As cases plummeted, for a while it even seemed possible to eradicate polio by the year 2000. Then came the creeping awareness that OPV was neither entirely benign nor as reliably effective as hoped in children in the tropics. Bottom line: The target date for polio’s death knell continued to slide. Today, sadly, eradication is still not assured. On November 30, 2018, a WHO committee met for the 19th time in four years only to deempolio, yet again, a public health emergency of international concern—a dubious honor previously accorded to H1N1 flu (2009), Ebola (2014), and Zika (2016). Theworst-case scenario in the near term? That, in 2019 and beyond, the global south will face double trouble if wild poliovirus type 1 infections in Pakistan and Afghanistan continue to stay flat or rise while circulating vaccine-derived polioviruses (VDPVs) also ratchet up and spread. In 2017 and 2018, paralytic cases caused by mutants of OPV type 2—a strain included in OPVs until 2016, when type 2 was deleted from the standard OPV mix used in 155 countries—were detected in the DemocraticRepublicofCongo,Niger,Nigeria,Somalia, andSyria. This confirms that neurovirulent OPV variants are still circulating, largely silent and undetected, in multiple sites worldwide where they can potentially afflict underor unvaccinated people. The time has come to reexamine the modern polio era. In Polio: The Odyssey of Eradication, recently published by Hurst and distributed by Oxford University Press, science journalist ThomasAbrahamdoes just that, first narrating polio’s historical and virologic backstory, and then interrogating its still-elusive eradication. Along theway, the author weaves actors frompast and present researchers, to global health leaders fueled by ego and dreams, to passionate, committed Rotarians and local stakeholders. All thewhile, Abrahampledges first and foremost to represent “the needs and aspirations of those in developing countries” and explicate “themessy reality that lies underneath an ambitious global health campaign, a reality the public rarely sees.” By quoting a rural Nigerian farmer from Kano Province who poignantly asks: “Why do you keep coming again and again to give polio vaccine? Why this polio, polio?” the author echoes the question ofmillionswho cannot quite fathomwhy a seemingly rare disease commands such an inordinate investment of time, effort, and money, while children in lowincome countries still die—day-in, day-out—of measles, malaria, and other deadly, ubiquitous blights. In the closing chapters of Polio: The Odyssey of Eradication, Abraham moves to recent geopolitical events: disinformation around polio vaccine, violence unleashed on polio vaccinators, and the bitter fruit of using vaccine-related subterfuge to locate Osama bin Laden in Abbottabad, Pakistan. But by this point, many readers will have concluded that the stage was already set for a lingering (and possibly unwinnable) war against polio thanks to assorted missteps and the world’s tortoise-like response to OPV’s sporadic mutation to a neurovirulent pathogen. All of these factors have handicapped polio’s final purge. Offsetting the gloom is polio’s stunning 99 percent decline over three decades—a true cause for celebration. In Abraham’s excellent marriage of narrative, reporting, and commentary, paradoxes abound. As a result, especially for tropical medicine and global health “newbies” seeking hard, nuanced truths, this book is highly recommended. After finishingPolio: TheOdyssey of Eradication, I wrote to a physician-researcher featured in its pages. Some have called Dr. T. Jacob John, an Indian pediatrician, medical virologist, and vaccine expert, “near-prophetic” for anticipating roadblocks in the polio endgame long before others either recognized or addressed them. As a record of intellectual independence, his long list of peer-reviewed publications speaks for itself. Early in our email exchange, however, one question I posed to John involved the dearth of women in the highest polio policy circles, a fact thatmayseemoff-topic to some—to others, bothsignificantandunfortunate. Inhis answer, Johnaffirmed the gender imbalance and expressed basic philosophic principles. Healso shared long-standingdismayover certain featuresof the Expanded Programme on Immunization [EPI] writ large and inherent flaws in the “OPV-only strategy” that, until recently, prevailed in the Global Polio Eradication Initiative [GPEI].