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Hello, beautiful people, Brandon Hewlett here, coming to you from Vanderbilt University, and this is the Filth in America podcast. On today's episode, we're going to talk about a disease that I think many of us don't think about much these days, but yet if you go back to the middle of the 20th century, as recently as the 1950s, it was one of the epidemic scourges of America. It really struck fear in the hearts of many Americans, particularly Americans who had children. Obviously, this is the heart of the baby boom time historically in America at that juncture during the 1950s. In fact, this particular disease was really on almost everyone's minds. Polls at the time showed that it was the thing that Americans feared the most behind only the atomic bomb. And if you think about it, that's remarkable to be that much in the minds of folks. And that disease, of course, is polio, short for poliomyelitis, a viral syndrome, a viral disease that has been around for quite some time. It's a historic disease, believe it or not. We even have some hieroglyphs from ancient Egypt that show the tell-tale paralysis that poliomyelitis causes. It was known throughout the ancient world. It was known for years and years and years across Europe. In fact, a British physician looks to do the first characterization of polio in 1789. A pediatrician in London publishes his first kind of description of paralytic polio in children. It was later characterized as long ago as 1840 in fairly great detail and has been with us ever since. Interestingly, though, polio in ancient times, certainly before the late 1800s, did not seem to occur in epidemics that much, which is really unusual. You have a disease that really changes epidemiologically its manifestation, right? It was not thought of as one of the historic epidemic diseases that was going around. And it wasn't until much, much later you start seeing some epidemics in Europe. In the United States, the story of polio epidemics truly started in an epidemic in Vermont in 1894. And that particular outbreak put polio on the map, and it was increasingly on the minds of Americans, particularly American parents, from that time for the next 60 or 70 years. Now we find it having naturally occurring epidemics in only two countries, Afghanistan and Pakistan, although you do see isolated cases that we'll talk about around. As we said, it's a viral illness. It is what we call a fecal oral disease, that is to say, it is oftentimes comes into the body through the mouth from contaminated water, potentially contaminated food, although I think water is much, much more common. The virus can infect the surface tissue in the oral pharynx, the mouth and throat, as well as the surface tissue in the intestines. And it replicates and is shed from both the oral pharynx and from the intestines into the environment, where then, of course, it would go on to infect others. It doesn't persist in the environment particularly long. It will die if it doesn't find another human host fairly quickly as viruses go, not immediately, but fairly quickly, which is part of the reason why you didn't see it for so long manifesting itself in a variety of epidemics. It just didn't do well. You needed a fairly large number and a fairly highly concentrated, a high density of people for it to transmit itself with maximal efficiency. So as we get into more and more urbanization that comes with industrialization at that time, you now have a good number of potential hosts very close to each other. So it's thought that the poliovirus would circulate fairly widely in the cities, but yet it didn't necessarily cause severe disease in most cases. After it infects the surface tissues and in either the gut or in the mouth, it can progress on into the lymphatic system, the lymph nodes in the area around the intestine or in the neck and the cervical nodes that we have there. From there, it can progress on to the bloodstream. Now, it doesn't always progress through these other later stages in people. Some of it depends on just the individual person, the genetic makeup, how they are health-wise, what their overall health status is. Oftentimes, healthy folks can fight off the infection, as with many enteroviruses. Maybe it would cause a mild flu-like illness. So you hear the stories of polio survivors. Many of them were out playing and just noticed some fatigue or some weakness in oftentimes their legs, and that was the beginning. So they've gone from kind of playing to not so much fairly quickly, right? It was around. From the blood, if it does progress, and most, again, most cases don't, even in the early 20th century, still about 70% of those infected didn't really show any sort of symptoms that we can assess without a whole lot of looking. Beyond that, only about a quarter of folks had symptomatic disease, and the vast majority of those would get better after maybe a little bit of fever, maybe a little bit of stomach upset or diarrhea or so on as the virus progresses through, but it wouldn't progress. If it did make it into the bloodstream, even then not everyone would progress beyond that. These folks would be a little bit sicker oftentimes with a high fever, maybe some pain in their bodies, just that achy, sick feeling. But in a small number of cases, it can progress on and infect nervous tissue in the brain and the spinal cord. And when that happens, there may be a paralysis, the thing that polio is most known for. Again, that is not the majority, it's by and large the minority of cases. And especially historically, we really don't think that these symptoms which gave what we now call polio's original name, infantile paralysis or juvenile paralysis, are really not the majority of cases, but they may be the majority of cases that were known to the casual observer. It's hard to miss paralysis. Now, that paralysis in many cases was not permanent. It would clear up and maybe go away after the individual cleared the virus from their system and started recovery. However, if the symptoms of paralysis that appeared within the first couple of weeks, two to ten days usually were there at 12 months, then they were almost always permanent. And they could cause, of course, disability for the rest of that particular patient's life. I think polio is best known for affecting the legs, and it does seem to do that pretty often. However, it can affect all the way up and down the body. People can have paralyzed chests. Unfortunately, it can paralyze the diaphragm, leading to problems with breathing, which can ultimately be fatal. It does kill from time to time. Again, historically it didn't, but as we move through the 20th century, it did seem to kill more and more folks and cause paralysis in more and more folks, owing to the fear that I think surrounded this disease. It wasn't something that was there in a lot of folks' childhood who were having children during the baby boom era, but now it is this Mr. Disease, and they don't know much about it. There doesn't seem to be much that can be done about it. Treatments were not particularly effective. It tends to occur seasonally. You would start seeing more and more polio cases in the warmer months when kids were out of school. A lot of kids visiting swimming pools and places like that seemed to be the nexus, but it was hard to say because so many kids we now know could be infected but not show any symptoms. The whole time this infection is going on in the gut or in the mouth, you are shedding virus. It could come out and then, of course, affect uh infect other people. It can certainly be shedding from an individual that is asymptomatic. It can in some cases continue to be shedding from somebody briefly after they've recovered from the illness. So it'd be very tough to track it down. And uh one of the things that we now know that was so paradoxical, was so interesting about uh polioepidemiologically, is it responded almost to the direct, indirect opposition of what we did to prevent other fecal oral illnesses, and that, of course, being water and sanitation activities. As we cleaned up the water, right, largely to get rid of other fecal oral illnesses or other epidemic illnesses, cholera in the United States most notably, but any of these other illnesses, and in fact, sanitation and clean water are some of the most important public health innovations ever in terms of both preventing disease and preventing death, polio seemed to increase. And the thinking we now believe is that before polio was epidemic, right, as urbanization occurred in the 1800s, uh. starting from a very early age, very early age indeed, as infants. The thing about it is that uh infants who are being breastfed receive some antibodies to diseases that the mother has been exposed to through the breast milk, and so they are somewhat protected from a lot of diseases that are in wide circulation. And polio was no exception. The mother would continually be exposed, so she would continually be producing antibodies too, which would then be passed to her baby through the breast milk. And as that baby was exposed up through the first, say, year of life, year and a half of life, the whole time they're getting these antibodies, the baby probably did become infected with the polio virus. But because it had these circulating antibodies in its body from the mother, the progression of polio through these other tissues, into the bloodstream, into the lymphatic system, and ultimately to cause paralysis and stuff really didn't happen because those antibodies were there to protect the baby. And all the while, as that baby's immune system is maturing, um, the baby too starts producing their own antibodies and the cycle continues. So as they were continually exposed, they continued to produce antibodies. So you really just got very isolated sporadic cases going on until the water started being cleaned up. And more and more of the disease-causing organisms, polio included, were removed from more and more water supplies. Now, what happens with that is that children are exposed to polio for the first time at an older age than they once were, right? And we know now, and I don't think we knew then, but we know now that the way polio manifests is very different depending on when you first encounter it. As we said, if you encounter it first as an infant when you have some maternal protection, you rarely develop a lot of the symptoms. It can happen, but it's not all that common. But if you get exposed later when you don't have maternal antibodies circulating through your body, and you don't have any of your own antibodies circulating through the body, you are more vulnerable to some of the severe manifestations. And as we look through it, the older you are when you first come in contact with polio virus or are first infected with the polio, the more likely it is that you suffer some of the severe symptoms of infection, including some of the paralysis that so scared people in the mid-20th century. So it really was a consequence of the progress of immunekind. You had these two things, urbanization and increased high-quality water supplies combining to change the epidemiology of polio from just an everywhere ubiquitous uh virus that infected almost everybody, but didn't cause outbreaks and didn't really cause much in the way of disease to something that didn't actually infect that many people overall, but when it did, tended to occur in outbreaks, in epidemics, and was increasingly likely to cause this devastating disease in maybe 1 to 5 percent of cases, depending on uh when it is, where it is, and what you're looking at. So if you are a parent uh in the 1950s, you certainly probably didn't have a whole lot of experience with polio as a child. You probably didn't know a whole lot of childhood friends that had gotten these severe diseases, even though they had happened, but you just didn't because they weren't as common. And now all of a sudden, it seems like polio is everywhere. Indeed, in the early 1950s was the peak of both polio infections that are well described and cases of these very debilitating consequences of polio infection, some 21,000 folks in 1953 affected. And it tended to occur, as we said, in the warmer months. Kids were out playing and they would get they would come down with some sickness, and it was really, really scary, I think, for the patients not knowing. And it didn't seem to the people of the time that there was anything much that could be done about it, even though more and more knowledge about the organism uh slowly came in. Now, it's a virus, it's not bacteria, it's harder to grow, it's harder to study, it takes longer to fully characterize, but people have been characterizing it or trying to characterize it for over a hundred years by the 1950s. So there were some things known, it was known to be a virus by then, but viruses, like we said, are tough to grow. There was a big uh outbreak in 1916, along with everything else going on in the disease world around that time, which resulted in some 2,000 deaths each summer. We did have smaller outbreaks around the 1916 New York outbreak was one of the ones that had the most fatalities, but it tended to occur notably in the early 1920s. It uh infects and ultimately paralyzes Franklin Delano Roosevelt after a day out on the water. And I think it is that one infection and that one very consequential change in one man's life that truly changes the way polio goes for the next several years. Not immediately. It is the infection and the ultimate activities of FDR that changed the route in ways that I don't think even he could have expected at the time. You know, there's a lot of descriptions of him out on the water. He was a very vigorous, very robust guy with a, I think, a bright political future at that time. He was Assistant Secretary of the Navy, and was, of course, from a fairly prominent family, very wealthy, who was well known. And I think a lot of folks, had you gone to them in 1920 or 1921, said, you know, this guy's gonna be president someday, that wouldn't have surprised them at all. Obviously, he had run for other offices and was doing quite well, and he was struck down by uh the disease. He was older, you know, he was in his late 30s than most polio uh victims were, but nonetheless, he did get one of these bad cases and he did lose uh the use of his legs permanently, and he was in really kind of a feeling of despair for quite some time. But he ultimately, as we know, comes out of it and goes on to become the president of the United States during some fairly difficult times, right, during the Great Depression. Along this road in 1926, he comes in contact with some folks at Warm Springs, Georgia, uh, and he ultimately takes over, uses most of his inheritance, actually, to do this. He takes over a facility at Warm Springs, Georgia, and transforms it into what today we would call a rehabilitation hospital. There really wasn't such a thing at that time, but he very much transforms that place into a modern rehabilitation. Now, there was some discussion and some thinking that the water of the springs seemed to have some sort of healing properties for folks that had been affected by polio and had the resultant paralysis. I don't know that there's a whole lot to that in terms of uh a true medicinal value of the water, but the the water did allow folks to get in at various times uh throughout the year. It was a warm spring, and Georgia, of course, was warm. So they folks could come down there and they could swim, even if they didn't have the use of their legs, which was generally good for their health. We know the benefits of exercise. We know the benefits of physical activity generally, and I think this is true of folks dealing with the ramifications of paralysis, and certainly uh if they could get the rest of the body uh back, they would they would go on to live more productive lives. Uh there is always the possibility in polio victims that muscles that were not affected by their paralysis could be used in some cases to restore function or improve function or overcome the weakness in certain uh muscles that were not functional because of nerve damage related to the poliovirus infection. So it was an important step forward. Um FDR becomes president. Again, this is the Great Depression era. He obviously can't run Warm Springs, Georgia, can't go on. So he turns the facility over to a man by the name of Basil O'Connor, his law partner. Now, O'Connor is an interesting guy. He is a hard-scrabble Irish guy, obviously children of immigrants. He never really had a whole lot in terms of money growing up and whatnot. He really had to fight for everything that he got, and he had that kind of aggressive, very practical, hard-charging personality. He wanted things now. He wanted to continue on. He, by his own admission, never did think that he would be involved in public life or in anything charitable. That really wasn't the way he thought about things, wasn't what he was interested in. When he was interviewed later, he really never said that he would be involved in what he called these do-gooder activities. But he was very loyal to FDR, and they were very close friends. So when FDR turns over Warm Springs to Basil O'Connor, he really takes it and runs with it. He shores up the finances, he turns it into a foundation, a charitable foundation, and begins looking to raise money to keep this thing going. Now, this of course is the depths of the depression, right? Now, traditionally at the time, philanthropy was the provenance of very wealthy individuals and very wealthy families, right? We know of the of the charitable works of the Rockefellers and Carnegie's, and certainly here at Vanderbilt, right? It's a Vanderbilt charitable donation. And that's how you did it. That's how things happened. You worked out relationships with these prominent families. Remember, we're kind of coming out of the Gilded Age and the robber barons and all these things. And they supported all these charitable activities. As the depression continues on, that no longer works, right? You have a huge demand for the traditional functions of charitable organizations like churches and soup kitchens and so on, because there's so many more people out of work, the economy is grinding to a halt. But when you have this, right, businesses are not particularly working very well. There's not a whole lot of excess capital. A lot of people have lost significant sums in the stock market or in other holdings or businesses that go belly up. So there is kind of a double whammy of increased demand for the traditional charities that these high net worth individuals supported, and less money available to these folks to support those charities. So Basil O'Connor really has to kind of go back to the drawing board and reinvent how philanthropy is going to be done and how these foundations are going to run. If he's going to have any chance of keeping this charitable, which was doing great work, but I mean it was really thought of as just one other charity. All these charities were doing great work. And there was just so much need at the time. And so few of these high-net worth individuals that continue on that had the money to continue. And so people's donations started getting focused. And so Basil comes up with this idea. Ultimately, they found the Infantile Paralysis Foundation. But he has an idea, what if they flipped the concept of philanthropy on its head? And rather than having a few high-net worth individuals give a lot of money, what if a lot of everyday Americans gave money for this public health enterprise and gave what they could give? So you could have the power of a huge number of people giving a small amount and get the same net result, right? So he comes up with the idea for a campaign to get everyone to contribute a dime, right? Very few people were too poor to contribute a dime to help these needy children. And I think that really resonated with Americans at the time, even though things were really bad, even though it was rough on a lot of people, they could still contribute. They could still be a part of this movement. And so this campaign for folks to contribute a dime transforms the way we thought of philanthropy. And of course, he has a very good friend who's in a very prominent uh position, right? He's president. And so he leverages that and some of the other contributions he has to do a national campaign encouraging folks to send a dime to President Roosevelt at the White House for this foundation. He enlists the aid of celebrities, and this is really one of the first times that this is done on a large scale to do promotional messages. And so everybody went to the movie houses and would see they would get a little message about these things, and they were pamphlets and flyers, and Basil was a very good organizer. He was a very good administrator. He didn't really know, at least initially, very much about polio, but he could do all these other things. He organized chapters around and promotional activities and all these things for people to send a dime to the White House. And this campaign transforms the Impactile Paralysis Association into the March of Dimes. And the March of Dimes was really an unbelievably successful campaign at the time. In the depths of the Depression, I think the first ask it raises something like $1.7 million, which is an extraordinarily high sum of money at the time. And of course, Basil O'Connor comes up with second and third and really continues this particular way of fundraising that he's kind of stumbled onto and vows to provide care for all of these children that are polio affected. And of course, he has images of these children, and he has the celebrity endorsements, and of course, he has the president. So it continues on, and huge sums of money are raised that Basil puts into all of these care facilities, taking care of folks that have been affected by this particular disease. And it was really, really the first time you see something like that. And this combination of government and private fundraising activity going together for public health activities. And this continues on for a while, but Basil knows that he is somewhat in a race against time. Eventually, people say we haven't made any progress, or something needs to be done, you haven't done it, and that'll wear out. He also knows that something has to be done to stop this disease at its source, or it will just never end. And he's got to come up with something. So he wants to move into the vaccine space. And he is, like we said, he's a very assertive, very aggressive person. He's not a scientist, he's a lawyer, but well-organized, very highly motivated. He starts coming to meetings and other scientific conferences, and he pledges that the March of Dimes is going to contribute and support the development of effective treatments and indeed a vaccine to stop this scourge, right? And uh this continues on. Of course, when when World War II happens, uh a lot of efforts are derailed, but he still keeps at it. And fortuitously, he is on uh a ship coming back from a conference, and he has uh occasion to meet a fairly young and equally aggressive scientist, a guy by the name of Jonas Salk. And Salk is a researcher. Uh, he had been active in the Army during the war. He had done a lot of work with influenza vaccines and influenza prevention. And he and Basil O'Connor have very similar personalities, uh, very aggressive, uh, they are very focused, dedicated people, and they hit it off almost immediately. And this is fortuitous because Salk had the idea that was a little bit different than the conventional wisdom of the time. He believed in an inactivated polio vaccine, that is to say, a vaccine made from polio virus that had been inactivated somehow, chemically or by heat or whatever, and using that to generate immunity in people. Now, this was not the predominant thinking at the time. There were vaccines for yellow fever and smallpox, which are other viruses, and but the world the thinking in virology was you needed to use live virus, not inactivated virus, to generate vaccine. And the reason was it's not always that easy to inactivate a virus, but still keep it uh intact enough that it will generate an immune response from the person uh that you inject it into. And so that person will produce antibodies that protect them from infection with that virus, right? If you boil the thing and kill it, you're probably gonna destroy it and it's not gonna have any pieces left for the body to see and create antibodies to, or if you kill it chemically, the same thing. And it can be tough to pull this off. So the live virus vaccines is where you take a virus and you either in a lab or in a manufacturing facility treat it or run it through several generations of infections to decrease its ability to reproduce or cause severe symptoms in a person, but it's still largely intact. And then if you expose somebody to this weakened virus, or attenuated, as we call it, then they can produce antibodies, but the virus is probably not capable of causing them a whole lot of disease, so you get the best of both worlds. You get that natural protection, it is intact, so you the the body is able to make antibodies lots of different ways to different targets on that virus, and it would work. And that's what had worked in yellow fever and smallpox, and this has been going on for hundreds of years, in one way or the other by the time this was going around. And indeed, most of the scientific wisdom and some of the authorities in the area, including a guy uh who was of Russian origin, Albert Sabin, who's one of the leading virologists, said, you know, this is the way it needed to be done. And they were tended to be critical of Basil O'Connor. A lot of the scientific community were very traditional academics, and they, you know, didn't really subscribe to the idea of science on a timetable. They said, you know, you really couldn't say, well, we're gonna have a vaccine in five years or ten years or whatever it is. Uh Saban just kept saying we need to push this out. Um it's dangerous to try to come up with other things. Uh science moves at its own pace, and you'll get it when you get it. And we need to be a thousand percent sure this isn't gonna cause any problems, and so on, and so forth. And of course, Salk is the opposite of that. He is an aggressive person. He runs his lab very much like an industrial fashion. All of his people working the lab are doing various tasks assigned directly by him, trying to move things forward. He's not really interested in a wide variety of discoveries. He's very focused on the polio problem, where Sabin had the traditional lab where different researchers were working on different aspects and they're all kind of moving at their own pace and coming up with things. And that's, of course, to be fair, that's the way it was done, right? That's the way people thought about it. But with the connection between Basil O'Connor and Jonas Saul, Saug gets the resources that he needs. And there was another major discovery in the late 1940s. Another group of scientists very much demonstrates that they can culture the poliovirus in a variety of different cell types, making it possible to have lots of viruses available for research and lots of these other things that both Salk and Sabin would need to develop a vaccine. So Basil O'Connor really redoubles his efforts, which is taken up wholeheartedly by Jonas Salk, who is now infused with these resources, just does all kinds of things, and he's starting to get good results fairly early on. He develops an in-vactivated polio vaccine, and he uh ultimately is able to trial it in animals and see a very good antibody response to his new in-activated polio virus vaccine in animals, which is one of the first big steps. And so he is well on his way, and Saban the whole while is cautioning this is really a rush. You don't know what's gonna happen here. If you don't completely kill all these, you could be injecting somebody with polio virus. And since it's not attenuated, you could potentially cause disease in somebody. You're gonna give kids polio, is what he goes around saying. Basil O'Connor is undaunted and keeps funding Salk's research. Salk does some small trials in the early 1950s in orphans and homes for children that had mental disabilities and whatever else. I mean, in a lot of those trials, I think we would say were unethical and we wouldn't do today. They don't have informed consent and all of this. They just kind of do it. So if Salk wanted to do it, he would reach out to the director of an orphanage or one of these homes to take care of kids with mental disabilities. Uh he also trialed it on people that had had polio to see if he could maintain the antibody response, and he's got very good results in all cases in these early trials. So he makes the case that he needs to trial this on a large scale for safety and efficacy. He does give his preparation to himself and to his own children and very much notes that he's put his money where his mouth has, and it is, and I think there's value to that. And he did see an immune response in himself and in his family. And at this point, you know, fear and hysteria around polio is growing and growing and growing. As we said, it's really the thing that parents feared the most, and second only to the atomic bomb, so it's the only, it's the top disease fear. And there are a series of outbreaks in the late 1940s and early 1950s that are beyond what has ever been seen in the United States, really pushing the urgency. And Sabin doesn't seem to uh change his mind, but Salk gets it and they drive on. And so they look to do the largest clinical trial ever done. And they set out to vaccinate millions of children in the United States and to a less extent in Europe and some in Canada with this experimental vaccine. And so this all gets set up and organized by Basil O'Connor, who puts the money behind it. And local physicians, local public health officials actually were involved in this, and they start giving these injections in schools. And parents really rush, they line up to get their kids the opportunity to have this experimental vaccine, right? Nobody really knows what it's going to do on this large scale. It's nothing like this has ever been done, uh, not only on this vaccine, but ever. No one's ever done anything quite like this. It's the largest study of its kind at the time. Nonetheless, uh, people are clamoring for it, and it gets done in quite a few schools, and there's a huge number of children who ultimately get this vaccine this way. But there is a time issue there, right? There they still need time for the vaccine to work, right? So you have to give it. In many cases, they're looking at multiple doses in these uh kids. And so it takes a solid year. You've got to give it with this IPV, this inactivated polio vaccine, and then you've got to come back and see. And it is really one of the most anticipated things of the early 50s. This trial goes on, and then they have to wait. And the secret was the results of this test. It was very, very closely guarded. And they s O'Connor and Salk schedule a press conference a year after they started, and it was covered by everybody around the world. And remember at the time there's no Internet, right? There's no social media to disseminate, there's no podcast. Uh, so they have these physical press kits that they print in secrecy. They don't want anybody to scoop, and they have a meeting and announce that this vaccine is very safe and very effective. It prevents paralysis and 80 to 90 percent of the cases. I mean, it's unbelievable. This is front-page news all over the world, people just gobble it up, and then every school system, every town, everywhere is clamoring to get this vaccine available. So uh it's really a vaccine effort beyond what individual physicians can manage themselves. Really, the public health infrastructure is caused in, large notable clinics like Mayo Clinic and Cleveland Clinic, and all this are involved in rolling this out. And huge, huge numbers of children are vaccinated with the SOK vaccine. And of course, SALK is an instant uh celebrity around the world. And people start kind of questioning Sabin, like what's going on? What have you been doing this whole time? Saban, of course, been working on a live virus, which is oral. And he says, you know, we're moving too fast, it's dangerous, but people just barrel ahead, uh, I think partly fueled by scientific discovery, but partly fueled by fear, right? Parents do not want their kids to have to suffer through this thing, and we now have something we can do about it. And so this can-do mentality of that generation really drives and everything's going swimmingly, as you might say, until there is a few descriptions of kids getting polio after having been vaccinated. Very soon after. And then there's a few more, and then there's a few more, and they seem to be in certain areas, and they are very closely associated with kids who had gotten vaccinated. Now, nobody's really sure why this is going on. Once the trial results from the original SALT vaccine trial were announced, SALK licenses six different companies to produce vaccine. He doesn't actually patent it, kind of partly, I think, because of his tremendous ego, but partly because of the importance of what he's doing. People say, well, why didn't you patent this? You could be extremely wealthy. And he said, hey, can you patent the sun famously? And so there were different companies that were trying to make uh salks preparation to meet this huge demand. And there were starting to be a fairly significant number of kids that seemed to be having this adverse event to the vaccine, which wasn't described in any of the trials and hadn't been described everywhere. Um the Surgeon General himself actually gets fairly concerned and comes out and recommends a pause in these vaccine efforts, and an investigation is undertaken, and it's found that a single batch of this particular vaccine seemed to account for most of the cases of disease following vaccination, largely this batch that was made by the Cutter Pharmaceutical Company in Berkeley, California, and further investigations showed that these companies were really having trouble scaling up Salk's vaccines and SOX process, which of course had been designed in a lab and made that way, right? When they scale it up, there was a lot of quality control issues. There really wasn't a whole lot of government oversight or anything like that. There wasn't independent experts to kind of help out these companies or any of this. Undeterred, though, Basil O'Connor pushes on and they correct the problems at these companies and continue vaccines all and all done. The pause by the Surgeon General only lasted eight days. They figure out the problem, correct it. There were some governmental actions taken subsequent to that to form offices to To help oversee and make sure the quality control was there that hadn't been there, but they drive on. And then so many of your children are vaccinated, and the incidence of polio starts dropping dramatically. Now remember, it was a very scary disease, and I don't want to say it was not common, but it wasn't nearly as common as several other things, right? This had been a very focused effort on a very specific infection, and this very specific remedy was developed, and the intervention was having pretty significant success. The problem is solved, right? We have this vaccine, it's very effective, kids were lined up to get it. It became not just a school program, but now pediatricians do it in the office, and family practice physicians are doing it in their office. And it gets pretty rapidly accepted by the population at large. And incidence of polio, severe polio cases, drops to just a few hundred almost immediately, and then down into the double digits and over into the single digits very, very quickly. By the early 1960s, Saban, who had been around telling basically anyone who would listen, uh, see, I told you so when the cutter pharmaceutical problems start happening, had continued on developing his live virus, his live attenuated virus version, which was an oral version. And it had several advantages. It was an oral thing, you put it in liquid or a sugar cube. Some folks listening to this podcast may remember getting it that way, which is much, much easier to give, right? Kids don't like shots this way. You don't have to give them a shot. Um, it was very easy, relatively speaking, to manufacture, to make at scale. It did not suffer from some of the manufacturing challenges that SOX vaccines. It was cheaper, it was easier to give. And uh because it was a live virus, it had a whole virus in there. Uh it was attenuated, so it generally did not cause disease, but it it elicited a much more robust vaccine response. So of the three strains, you could ultimately develop a trivalent version, that's three-strained version that has uh viruses of all the different three types of polio, so it can give really good, strong immunity. Um so there were some switching going on in the United States, but people didn't really think about it. Uh in Europe, however, it's a different story. Uh Sabin, of course, himself was Russian, and he talks to the Russians, and the Russians end up doing a trial of the Sabin vaccine and find that it is superior in their estimation to the SALK vaccine, uh. Although both of them are very, very good. Several countries in Eastern Europe begin to use the oral Sabin vaccine as their go-to and don't use the SALT vaccine. Uh however, in something that was, I think, important in the Cold World world, the data was shared openly with special committees of uh the World Health Organization, and a committee chaired by an American reviewed the data and validated the trial data that had been done by the Russians and really argued for the use of this particular vaccine. So it becomes the standard for a lot of vaccine activities globally. It is cheaper, it's easier, and it doesn't have the shot thing. So this continues and polio rapidly is eliminated in the developed world. In some of the poorer parts of the globe, it continues on until you see some changes again in the way that global public health is done. In 1974, the World Health Assembly passes a resolution to create the expanded program on immunization to bring vaccines to the world children, largely spurred on by the success in wealthier areas of the SALK and Sabin vaccines. By 1985, another charity, Rotary International, gets into the picture and they launch Polio Plus, which was the first and really largest internationally coordinated private sector support of a public health initiative. And they make an initial pledge of $120 million to bring this vaccine to every child in the world. And I think that's not only a laudable, but it is a pretty big, big goal. But these are folks that were drink dreaming big in the mid-80s. Polio was still paralyzing more than a thousand children worldwide every day. But of course, it was not evenly distributed around the world, right? The wealthier countries where this was these vaccines were developed largely did not have to deal with it. The World Health Organization, World Health Assembly ultimately launched the Global Polio Eradication Initiative, which is a partnership of multiple countries and other charitable organizations. The Bill and Melinda Gates Foundation is involved with it, and uh UNICEF, the United Nations Children's Emergency Fund, the U.S. Centers for Disease Control and Prevention. They, by 1990, set up the Global Polio Laboratory to really aggressively track and intervene when outbreaks of polio happen and bring this vaccine to the world. So though the last case of while polio occurs in the Americas in 1991. By 1994, 80 million children are vaccinated in China in 1995. You have a lot of countries in the Eastern Mediterranean region. 87 million children are vaccinated in India. And of course, with this, the uh incidence of polio really just starts plummeting. Notable uh political leaders continue to get involved in 1996. Nelson Mandela launched the Kick Polio out of Africa campaign, and ultimately 420 million African children are vaccinated during national immunization days. A lot of the world stops experiencing polio, certainly stops experiencing large-scale outbreaks by the late 1990s. And success continues on by the late 90s. In fact, the U.S. Secretary General is negotiating truces between warring factions and, say, the Congo or Nosnowley, but other places to allow for this vaccination to continue. Western Pacific is free by the year 2000. And you have in the early 2000s, you know, you have uh some 575 million children that have been vaccinated in 94 countries. Most of the world is polio free by 2002, to include Europe and a lot of Africa by the mid-2000s. Another polio vaccine is developed that is even better and more robust and lasts longer. So this accelerates what's going on. And so that brings us to where we sit now with polio being largely eradicated in most of the world. Like we said, there's only two countries where you see wild continuing transmission, and that's Afghanistan and Pakistan due to a variety of issues there. But a curious thing also starts happening. The Sabin vaccine, as we said, was an oral vaccine, but it did have live virus. And one of the things that did happen with the Sabin vaccine is it kind of when it infected the vaccinated child, right? You would drink this vaccine, and it would, of course, set up a mild or very minor infection in the gut and the oral. And you did shed some virus while that was going on, but it didn't really cause disease in the vaccinated individual. But you could shed virus. Now, this virus, you know, it's a living organism. It goes through the normal evolutionary processes, and every now and again, it's very, very rare, but every now and again you would see some viruses revert back to their more virulent state where they could cause polio in the Sabin vaccine, this oro vaccine. And so now we see some circulating cases of polio that occur from virus strains that originated with the vaccination program. And when you have a large population of unvaccinated folks, they can get infected with this re-modified is the best way to think about it, vaccine strain, and get the disease. The person who is vaccinated with the oral polio strain doesn't get polio, but somebody who was not vaccinated, who might have been exposed to that person, can. And we see that occurring every now and again. In fact, there was a case in 2022 in the United States of somebody who was infected like that. And it's a concern. One of the things that we've seen in the wars that are going on now, in 2024 in Gaza, we started seeing some polio cases arise, and the virus that was recovered from individuals affected by that were descended from these Sabin strains, the attenuated strains, and because the breakdown of the public health infrastructure there, the there was a lot of vulnerable children who ultimately got infected, and a very few did get polio disease. So it's one of those things we have to stay vigilant. The vaccine is still widely available. Vaccination still takes place in some of these countries where we don't see wild outbreaks to ensure that we don't. It is still very common among military forces to get it. It's still a very common, well-funded initiative, but I think it is evidence that nature continues to come at us, right? And nature has a way of trying to survive the interventions that we do to control it. So this is also one of those things when it becomes out of sight, out of mind, indeed in the United States, today the oral Sabin vaccine is what we use. We don't really use the SART vaccine anymore, although there are certain times when you can use it, and immunocompromise children and so on. But it has the potential to come back. And all of this 50, 60, 70 years of progress in eradicating the scourge of a disease has the potential to be undone by a lack of vaccination. Because if you have a population that is not vaccinated, that gets exposed to it, again, particularly as older children, they are very vulnerable to the disease. The vaccine stops all of that, but it only works if you give it. If people don't get it, if they're hesitant to get it, then that opens up a wide range of really negative possibilities. So I think we're at a turning point with polio, and it's something to watch. Is this something that we're going to continue this long history of public, private, and charitable partnership that really change the way we think about philanthropy and continue to press on until we get the last vestige of polio out? I mean, there's there's less than 100 cases every year. We're on the precipice of truly eliminating it and truly eliminating the scourge. We've only done this with one other disease and smallpox. We could potentially do that. Or do we think of it out of sight, out of mind? Uh do the folks that talk about the dangers of vaccines, do they went out and stop what has been a truly, uh, truly remarkable effort against a disease that caused a lot of damage? We'll see. That's the the way public health works. And it doesn't ever come to an end. We've got to continue to go on. So I look forward to talking with you more on future episodes of the Filth in America podcast, where we'll discuss all the things public health in America and beyond. Thank you. Have a good day.