The Prevention Files: Tracking a dead(ly) disease

Although we recognize prevention as critical to our well-being, we often think of the actual ways of doing it as routine and unexciting. Think about vaccination: There’s hardly anything more routine than a child coming to my office, and the family and I reviewing the recommended vaccination schedule.

“So we’ll need the polio vaccine and the MMR this visit,” I might say. And that’s about it — right until I administer the quick jab after employing my usual distraction techniques, which usually serve to distract me more than my patients.

It turns out, though, that a disease we’ve long since eradicated from the Western Hemisphere is actually the source of intense funding, effort and hair-raising adventure elsewhere in the world. The last case of poliomyelitis, or polio, anywhere close to us in Delaware was in a little boy named Luis Tenorio, in Peru, in 1991.

If anything, we are more interested in the historical aspects of polio and little nuggets about polio: FDR had polio; the March of Dimes was originally founded by him to advocate for polio vaccination; and the iron lung was developed for one of its dreaded complications, bulbar paralysis, which paralyzes the muscles controlling breathing.

A.I. duPont Hospital for Children, in its beginnings as a rehab hospital here in Delaware, took care of children afflicted with polio. As I write from my office at the Eugene DuPont Preventive Medicine & Rehabilitation Institute, I am reminded of the men and women this facility served in its days as a rehab hospital — those who had polio in their childhood and may have developed post-polio syndrome as adults.

How fortunate, then, that I don’t have to worry about what parents in three countries still do: that their child might develop acute flaccid paralysis because they live in one of the last places on earth where poliovirus has not been eradicated.

Motivated partly by curiosity and partly to help, I joined a World Health Organization team a few years ago to travel to the “last frontiers” to figure out why polio was still allowed to run free. Joined by my friend, the writer Tim Brookes, we traveled through areas of northern Pakistan and the Pakistan-Afghanistan border, which most people see only on TV, courtesy of the war and the Taliban. It would take a book (perhaps the one we wrote) to describe it all, but the main impression I came away with was not surprise that there was polio still here, but amazement that it had ever been controlled.

Polio requires very high levels of the population to be vaccinated. When you are dealing with barriers both physical and cultural — those involving mistrust of persons not from the remote villages of the region — that makes it much harder.

At one point, we had to recruit female nursing students from the particular villages to even get close to the large, multi-family compounds that dot this rural landscape. The fact that most of the compounds were heavily armed did not fill us with confidence, either. Tim and I had made our lists of whom to contact in case of disappearance ahead of time. Yet our preconceptions were continually supplanted, usually by acts of extreme kindness and professional commitment. Our WHO colleagues worked tirelessly in extraordinary circumstances, knowing their individual efforts as vaccinators in a rural part of a poor country would never be recognized. Among those we met who had the least to offer, we were given tea and food as a gesture of hospitality. It turns out, the same honor code which we interpret as aggression toward outsiders is in some circumstances full of consideration toward those same outsiders.

Even encounters with the Taliban, singled out as villains of our American narrative, were not so easy to categorize. After the 2006 earthquake in Pakistan — the biggest ever recorded there, with over 100,000 dead — their “social work” arm was the only one active there, getting villagers to safety and erecting makeshift camps.

It is said that travel broadens the mind, and it is certainly true. Yet one of the most important lessons of eradicating a nearly dead, yet still deadly, disease was very local: the realization that the only reason we still vaccinate kids in Delaware against polio is that it exists in Afghanistan, Pakistan and Nigeria — the last strongholds. Once it is eradicated (as smallpox was in the 1970s), shortly thereafter the need to vaccinate Americans and everyone else will go away.

It is rare that a case for caring about what happens abroad, “over there,” applies so directly to our prevention efforts here in Delaware. But I saw much in common that the dedicated vaccinators in the US — school nurses, public health workers, physicians — share with their sweaty, toiling, cooler-carrying counterparts in the arid north of Pakistan. As with all prevention efforts, it’s what we don’t see that sometimes makes the biggest difference.

So listen up, kids: Get your shots. It’s more important than I hope you’ll ever know.

Update (12/6/12): Periodically, one gets news that there have been setbacks in the polio vaccination program. Here is a story from this week: “A Polio Outbreak in Pakistan Reveals Gaps in Vaccination”

It highlights two important points: one, the polio vaccine given in the three countries which still have the disease, is not the same vaccine as the one we use. In the US, we use the polio “shot,” which does not contain live virus. However, in “polio-endemic” areas such as Pakistan, Afghanistan and Nigeria, polio “drops” are given. These live-virus drops are usually much better than shots in these situations. But if there aren’t enough kids who have received the vaccine already, the live virus in them can (in rare cases, like in Pakistan) cause polio.

Aside from safe water and sanitation, there is probably no single advance in health that has saved as many lives as immunization. We are nearly there with polio as well. So I’ll amend the moral of the story: Get your shots (or drops), kids.

On a personal note, the story of a child getting polio — something that simply should not happen in the 21st century — reminded me of one of the reasons I got involved in this work. My eldest cousin was never vaccinated against polio. I don’t know why; I never asked my family, since it didn’t seem to matter at that point. He developed paralytic disease at a young age, and although he had a productive professional life in the United Kingdom, he and his family were affected forever. Bill passed away a few years ago, and although I did not know him as well as I would have liked to, I always thought of him when I worked in the field.