Book Review: Polio: An American Story

Title
Polio: An American Story
(Winner of the 2006 Pulitzer Prize in History)

Author
David M. Oshinsky
George Littlefield Professor of American History, Department of History, University of Texas

Publication Date
2005

Publication Information
Oxford University Press; 288 pages

Reason for Reading
I had a couple reasons for reading this book. As you may have noticed earlier, I have a general interest in medical history, specifically epidemiology-related books (such as The Great Influenza, Asleep, etc.), and this fits right in with those. Additionally,the University of Michigan School of Public Health has had some notable influences on the polio vaccine, as Jonas Salk worked here prior to moving to Pittsburgh, and his former mentor analyzed the field trials of his killed-virus vaccine to determine their safety & efficacy. As such, I’ve already heard Salk mentioned at least a couple times in the official visits I’ve had here. They’re quite proud of it.

A Little Extra Background

Before Vaccines from Film Factory on Vimeo.
There are a number of other short (~1 min) clips on various topics related to polio and the vaccine on that page.

Synopsis
While titled "Polio: An American Story," this book might just as easily have been called "The Polio Vaccine: An American Race." The book is mostly set between 1921 (when FDR develops polio) and 1955 (around the time the vaccines were released), although a minimal amount of the book is set outside that time. The author focuses distinctly on two things during this time period- the rise of the National Foundation for Infantile Paralysis, and the race for a vaccine which ultimately developed from the foundation. To do so, he describes the circumstances of a small group of people, notably Franklin Delano Roosevelt, the most famous sufferer of polio and most ardent supporter of the NFIP (aka the March of Dimes), as well as Jonas Salk and Albert Sabin, the two primary men involved in the alleged race to find a vaccine.

In discussing the March of Dimes, the author initially details its inception, then goes on to describe many of the foundation's innovations that revolutionized fund raising and charity giving, which made them phenomenally successful. There is also a brief section on the initial decline of the March of Dimes once the vaccine for polio was discovered and how they tried to adapt using other singular diseases.

As for the vaccine race, despite the overall success by all parties involved (the March of Dimes in funding Salk's killed-virus vaccine and also Sabin's live-virus vaccine to a lesser extent, as well as Salk & Sabin as individuals), the story is also sad in a number of ways. Most notable is the bitter feud between Salk and Sabin over whose vaccine was better that lasted the rest of their lives. Both men died believing his own vaccine to be superior (though with merit on both accounts). Additionally, the government botched their role in the dispersal of the vaccine. This seemed mostly due to the Eisenhower administration's philosophy on government involvement (as noted in the book, one of the earliest potential national health insurance plans had recently been rejected). This turned out to be somewhat of an embarrassment for the administration, leading to the resignation of the female head (resulting in a backlash against women in that position in the first place). An interesting twist to this is that with the success of the Salk vaccine, the US didn't have much interest in testing Sabin's vaccine, so instead his testing was done in the Soviet Union.

Review

One thing I noticed in this book is the focus on those men most associated with the disease or those most visible to the public, as mentioned above. The few other books I have read on historical medicine rarely centered around individual people; however, the search for the polio vaccine was ultimately successful in the US, while in most of the other books, the diseases remained an enigma. As such, in those stories, the disease remained the focus instead of the people who conquered it.

In calling the book "An American Story," the author makes clear that he keeps his focus in the United States. I think this amounts to a minor shortcoming of the book, as one hypothesis is that as a country becomes cleaner, polio becomes more endemic. Yet with case examples at the ready, no mention is made to prove this. I would assume this is due to marketing the book to a history audience moreso than a science audience. For all intensive purposes, the story does seem to be mostly an American one, in that polio incidence seemed to be increasing more in the US than elsewhere, and the vaccines to end it were developed here. The only mention of any other country is the trials in the Soviet Union of the Sabin live-virus vaccine.

A brief section that caught my attention was that Jonas Salk was investigated by the House Un-American Activities Commission for potential communist leanings. His investigation is not entirely surprising because he apparently was in some far left-wing political groups in his college years and just after, before settling in and focusing intently on his research. But it makes me wonder who all among prominent scientists in the US were investigated at one point or another, considering Oppenheimer was also investigated and largely shamed, despite his role as basically a war hero.

Overall, it's a very informative book, and if you're interested in either polio, the WWII era, or government involvement in vaccines & health care issues, it's a valuable resource. I'd like to say it's written well, though I don't really have an example of poor writing of medical history against which to contrast it. What I can say for certain is that the book held my attention and I read the majority of it within a couple days, which is rare if the reading is dull. I would definitely recommend it, and once I come up with my own unique rating system (stars/thumbs up or down/etc), I'll try to give it an official rating.

Quotes
"In truth, polio was never the raging epidemic portrayed in the media, not even at its height in the 1940s and 1950s. Ten times as many children would be killed in accidents in these years, and three times as many would die of cancer. Polio's special status was due, in large part, to the efforts of a remarkable group, the National Foundation for Infantile Paralysis, which employed the latest techniques in advertising, fund raising, and motivational research to turn a horrific but relatively uncommon disease into the most feared affliction of its time." (5)

"The Salk trials would have a profound impact on the federal government's role in the testing and licensing of future drugs and vaccines. And the prospect of vaccinating children en masse, free of charge, would lead to a furious debate among doctors about the perils of 'socialized medicine.'" (7)

"Public perceptions of the physically disabled had begun to change. Older views of the cripple as a hopeless burden on family and society, best hidden in an upstairs bedroom or a dreary institution, had given way to more positive notions of recovery, thanks in large part to the example of FDR." (45)

"Until the 1940s, authorities in Pennsylvania had allowed public institutions to host all sorts of medical experiments. But times had changed; in 1944 the attorney general had intervened to stop a major vaccine trial at a state facility, claiming the government could not allow patients to be used as 'guinea pigs' in a project where 'many might suffer serious side effects' and 'some might even die.' There was a loophole, however. The 1944 ruling had involved a drug company that hoped to market a measles vaccine for profit." (157)

"On the key point, however, Salk refused to budge. There must be no placebo. He could not deny his own product to those who volunteer to receive it. If thousands of children were going to be injected, then every one of them deserved the benefit of his vaccine. The object of these trials should be to protect as many lives as possible, not to run a textbook experiment." (180)

"Volunteering, therefore, was cast as a privilege bestowed upon youngsters special enough to be called "polio pioneers." On the parental consent form, the standard phrase 'I give my permission' was changed to 'I hereby request,' implying that not every child would be fortunate enough to be picked." (191)

"Salk had a point. The addition of Merthiolate appeared to reduce the effectiveness of killed Type I poliovirus. Salk wrote increasingly frantic letters to Rivers and Francis, listing the numbered lots that he knew to be seriously weakened by the preservative. He hoped that accommodations could be made, that Francis might either discard these lots or, at the very least, take note of this problem in writing his final report. But Francis remained noncommittal; the decision would be his alone to make. 'The Merthiolate spoiled the vaccine,' Salk bitterly recalled. 'The field trial would have been close to 100 percent effective if the Merthiolate hadn't been rammed down my throat.' It was a lesson he would not soon forget.'" (201)

"What Salk didn't mention that night--and really wasn't obliged to--was that both the National Foundation and the University of Pittsburgh had seriously considered seeking a patent for the vaccine before finally abandoning the idea, and that a key reason for not doing so was Salk's own skepticism, as laid out in a frank meeting with patent attorneys who had visited his Pittsburgh laboratory in 1954." (211)

"In a sense, Salk was validating what his critics had been (and would be) saying for years: there was nothing really novel or dramatic about his vaccine. It was old science--a stopgap measure to be used until something better came along." (212)

"In truth, it wwas the model of democratic Canada--not Communist Russia--that the drug companies feared most. To the north, the government had taken immediate control of the polio vaccine with overwhelming popular support. The job was easier; Canada had far fewer children to inoculate. But the government-produced vaccine would prove to be safe and cheap and plentiful--a testimony, it appeared, to months of meticulous planning by the Ministry of Health. In Canada, polio was viewed as a national crisis requiring an appropriate national response." (219)

"'We're prisoners of our own success,' a prominent researcher observed. 'When formerly dreaded diseases are pushed into the shadows--or eliminated--questions about the vaccines themselves begin to spring up.'" (282)

Further Reading
Gawande, Atul. "The Mop-Up." Better. New York: Picador, 2007. 29-50. Print.

Offit, Paul. The Cutter Incident. New Haven: Yale University Press, 2005. Print.

Global Polio Eradication Initiative