TCA, vol. 36: The world loses a polio fighter.
“Didn’t we cure polio?”
I answered this question a lot between the years of 2000 and 2005, when I was doing my doctoral work on polio replication. Often, I attended scientific poster presentations and university dog-and-pony shows to raise funding for the department and college.
Sigh. “No, polio has no cure. We don’t have polio outbreaks anymore in the Americas because of the vaccine that prevents it, but it’s still prevalent in other parts of the world and there’s no cure for the infected”, I would answer. Again and again.
Another reason we studied poliovirus in our lab was because it is considered the archetype or “type species” of its class of viruses. Polio is the perfect example of its group, the Picornaviruses (pico=very small, RNA= it has RNA as a genome, virus=you get the drift). Pretty much everything discovered about polio would also be true, at least to some degree, about every other Picornavirus (which includes Hepatitis C, the common cold virus, hand foot and mouth disease virus, and many intestinal viruses). Additionally, since there is a vaccine for polio (and there is no vaccine for any other human Picornavirus) you can study polio in the lab without fear of becoming infected by your own experiment.
For those brave souls who are interested, here is a link to my dissertation: Requirements for Efficient Initiation of Poliovirus Negative Strand RNA Synthesis.
The Death of Paul Alexander.
After a series of American polio outbreaks in the 1950’s, there were 1,200 people who required an iron lung to live by 1959. In 2004, that number was down to 39. Last week, Paul Alexander who held the Guinness Book of World Records for living in an iron lung the longest, passed at the age of 79 after hospitalization for COVID. There is one last American still living in an iron lung, Martha Lillard.
Paul lived in an iron lung for over 70 years after being paralyzed by polio at age 6.
Paul was a tireless advocate for polio awareness and for the importance of polio vaccination using social media sites like TikTok, where he amassed hundreds of thousands of followers.
His list of accomplishments is impressive. He was one of the first home-schooled students in Dallas and graduated second in his high school class, even though he never actually physically attended his high school. He received Bachelors and Juris Doctor degrees from the University of Texas Austin, where he actually lived on campus in his iron lung and was assisted by fellow students. He learned to spend a short amount of time outside his iron lung by learning “frog breathing”, a technique of gulping down small amounts of air with the muscles of the throat (he was completely paralyzed beneath the throat). This allowed him to attend classes in a wheelchair.
He passed the bar exam and became a practicing lawyer in Dallas, seeing clients from his iron lung in an office downtown. He also wrote a memoir published in 2020 by tapping the keys on a computer using a stick controlled by his mouth.
Life in an iron lung.
An iron lung was a type of negative-pressure artificial respiration machine. It’s a long metal tube that the patient lays in with their head sticking out one end. An electric-powered pump removes the air from the tube, creating a vacuum that causes negative pressure in the tube. Air flows from areas of positive pressure to negative, so air would then flow into the patient’s lungs. The pump then releases the negative pressure and the air flows back out of their lungs. The pump can be hand-cranked if the power goes out, although its laborious. Polio survivor Dianne Odell, who spent 61 years in an iron lung passed in 2008 when the power went out in her parents home and an emergency generator failed. Her elderly parents were unable to hand pump the machine long enough.
There are other ways of assisting someone to breathe: portable negative pressure ventilators like the cuirass, positive pressure ventilators like masks that force air into the respiratory system, and intubation or placing a breathing tube in the lungs through a surgical opening in the throat.
For Paul, and many others like Martha and Dianne, an iron lung may be preferrable for the majority of their day. Polio not only paralyzed the body, but as the muscles atrophied and withered away, the limbs and torso may become severely contractured and deformed. Sitting up may not be possible, or may be very uncomfortable. Positive pressure vents push air into the lungs and can cause damage to the delicate tissues. Breathing tubes may prevent you from being able to speak and often cause chronic respiratory infections. Sometimes iron lungs are the best choices in these special circumstances.
As time went on, fewer and fewer iron lungs existed in America. Eventually, it became impossible to find someone who knew how to repair them or to find replacement parts. This happened to Paul on several occasions and in 2015 his iron lung began to leak air. A plea was sent out on social media for help and, unbelievably, just 10 miles down the road the owner of a mecahnical engineering shop had acquired two iron lungs at a clearance sale and was storing them at his warehouse. The owner refurbished them, even building some parts from scratch, and donated one to Paul, whom he had never heard of before this.
The State of Polio.
Polio infections still occur and are considered to be “endemic” or “non-endemic”. Endemic infections are when polio is constantly circulating within a country. Non-endemic infections are when a person gets infected by someone traveling, or were infected when they themselves were traveling into an endemic country. It’s when a case of polio pops up in an area where it does not routinely circulate.
There are only two endemic countries left in the world: Pakistan and Afghanistan. India and Nigeria were crossed off the endemic list in 2011 and 2015, respectively, although cases still crop up there from time to time (imported from other countries).
The Global Polio Eradication Initiative has been underway tirelessly since 1988. It is the largest international public health intiative in history and its contributors include: the WHO, UNICEF, the Rotary foundation, the CDC, and the Gates Foundation. Polio eradication has been extremely difficult though. Obstacles include:
the hardiness of polio. The virus can persist outside the human body for weeks at a time in contaminated water, causing long-lasting outbreaks.
the virus is highly contagious, spreading faster than containment efforts can control it.
90% of polio infections are asymptomatic, meaning people are infected and contagious but don’t know it. It’s hard to identify them and isolate them.
Antivaccination sentiment. Many people are weary of polio vaccination for religious and cultural reasons or because of mis/disinformation.
Lack of health care infrastructure in poverty and war stricken countries.
Rampant corruption preventing the efficient rollout of vaccine distribution
There have only been two other diseases completely eliminated from the Earth: smallpox and rinderpest (an animal disease).
How the war on terror set polio eradication back.
Many Pakistanis and Afghans were already leery of the polio vaccine. It was rumored for years that the polio vaccine was a Western plot to kill or sterilize Muslims. In an effort to improve the uptake of the vaccine, polio vaccine production was switched to Morocco, a majority Muslim country. Public health officials spent years in the field gaining trust with families, working with local religious and cultural leaders to put out good information and build community.
Then, the CIA stepped in.
In 2011, the CIA began a covert campaign in Pakistan to identify the whereabouts of Osama Bin Laden’s hiding place. A fake Hepatitis B vaccination campaign was begun who’s real goal was to collect blood samples from Pakistani children and sequence the DNA to try to identify relatives of Osama Bin Laden. The idea was that they could zero in on his family and discover his hiding place. The word got out about the operation. Pakistan-US relations took a huge hit and the residents of the area became distrustful of any vaccine and any health care worker. The Pakistani doctor associated with the initiative was arrested in Pakistan for assisting US intelligence agents. Pakistan saw its polio cases skyrocket after people started refusing any vaccine for their children. 60 polio vaccination workers were kidnapped and killed over the following four years, accused (wrongly) of being secret agents.
Pakistan still bears the world’s highest rate of polio infection.
And I’m still pissed at the CIA.
Complacency in America.
There are three umbrella reasons that people deny vaccines in America for non-medical reasons.
Confidence: lack of trust in vaccines, public health, doctors or the government.
Convenience: lack of access to vaccines, information, or health care.
Complacency: the idea that the diseases are not really that bad, not prevalent, or nothing to worry about and so the vaccine is unnecessary.
Polio falls squarely into this last category of complacency. Most parents today have never known anyone with polio or think (wrongly, as my college dean did) that polio has been “cured”. And so they think vaccinating their children for polio is unnecessary. In this sense, the polio vaccine has been a victim of its own success…. the vaccine works so well that no one even knows about the disease anymore. In fact, the average person probably has heard way more stories about vaccine side effects than stories of people with polio infections. So, vaccines start to seem more scary than the disease itself.
When vaccines work, nothing happens (you don’t get sick). It’s easy to fall into the trap of complacency. Compare that to medication: you feel crappy, you take a pill, you feel better. The pill is awesome! For a vaccine: you feel fine, you take a vaccine, maybe you feel some vaccine side effects. Why the hell am I taking this vaccine?
That’s why the visibility of people like Paul Alexander is so important. It is imperative that we don’t forget about diseases like polio, because believe me, polio will not forget about us. It is just one plane flight away, as was discovered in Rockland County, New York in 2022.
Sidebar: As I read through the CDC report linked above, I realized that one of the authors was a former student of mine in my Virology class at GSU. And I damn near cried of joy.
An unvaccinated American man became infected and paralyzed by poliovirus and poliovirus was discovered in the New York sewage system for two months afterwards. It is currently not known how this man became infected, but it is known that he was infected with the Vaccine-strain of poliovirus.
The polio vaccine used in most countries, including the USA, is the IPV which does not contain live polio virus and absolutely positively cannot cause polio infection. But the vaccine used in Pakistan and Afghanistan, the OPV, does contain live mutated poliovirus. This vaccine is made by taking poliovirus and mutating it so that it can no longer cause disease, but can still replicate. The OPV therefore is more powerful and causes a person to be more immune to polio: very necessary in endemic countries.
In very rare circumstances (like one in many millions) the OPV vaccine-virus can mutate back to its original disease causing state and infect the recipient with polio. Most likely, a traveler who received OPV in Pakistan or Afghanistan came to America shedding the vaccine-virus in their stool and infected this New York resident with a rare reverse-mutant vaccine virus (work is currently underway to make a safer OPV vaccine that reverts less often, or not at all). But it just goes to show you how easily this could happen with wild polio too. All it takes is one infected person to hop a plane and cause an outbreak in the unvaccinated communities in America.
Let’s not go back to this.
RIP Paul.
Stay happy, healthy and informed.
Jessica at TCA
Snowdon, C. The man in the iron lung: How Paul Alexander lived life to the full. BBC, 2024.
Alexander, P. Three minutes for a dog: my life in an iron lung. 2020.