Polio Vaccine

April 12, 2005
Prepared remarks by Dr. William Foege, recipient of the 2005 Thomas Francis, Jr. Medal in Global Public Health

"Duty, honor, country," will always evoke an image of Douglas MacArthur, standing at a lectern at West Point.

“Safe, effective, potent,” in public health circles, will always evoke the image of Dr. Thomas Francis Jr., standing at this lectern, in this auditorium, facing an overflow audience of scientists and reporters, such as Fred Friendly and Edward R. Murrow, to describe the vaccine developed by his student and mentee, Jonas Salk.

It was a moment in history, that day 50 years ago. A wonderful moment, but only a moment, and as with all moments, a moment to be understood in context. If you are younger than about 55 you have few memories of that time… the year James Dean and Dale Carnegie died, and Disneyland was opened.

You would not understand us older people talking about wearing coonskin caps because of Davy Crockett on TV.

The spring had other science interest. One month earlier Alexander Fleming, the discoverer of penicillin died. Within a week of this great moment in science, Einstein would die.

Some things would be very familiar... as if nothing has changed. For a week earlier Richard Daley was elected mayor of Chicago.

Some things seem futile in hindsight. New York was busy installing, at the busiest intersections, signs that read “Don’t Walk.”

But on that day, 50 years ago, the science history book was opened… opened in the middle.

The previous chapter made clear that those of us here are direct line descendents of the beginning of modern public health. Modern public health started 209 years ago this spring, when Edward Jenner, after 12 years of study, took material from the cowpox lesion of Sara Nelms and vaccinated James Phipps. Several weeks later he tried to give James Phipps smallpox and found him to be immune.

Vaccinations began being used in England and by 1801 Thomas Jefferson had acquired smallpox vaccine and personally vaccinated his household and his neighbors at Monticello.

It was at the memorial service for Jonas Salk that I listened to Charles Merieux, as he described the immunization family tree. Charles Merieux was one of the grand old people of immunization who died in January, 2001 at the age of 94. In his home in France, he once showed me a picture of his father, working in the lab, at the side of Louis Pasteur. Think of that compression of history. 

Charles became famous in public health circles in the summer of 1974, when in the midst of a meningitis outbreak in Brazil, he kept his staff at work during the traditional August vacation break to produce 100 million doses of meningitis vaccine, with 90 million of those doses given over the next 6 months.

At the service for Jonas Salk he talked about globalization and the immunization inheritance from 18th century Edward Jenner in England to 19th century Pasteur in France, to 20th century Salk in the United States. It was Pasteur, who at a meeting in London suggested that while the word vaccination actually applied only to the use of vaccinia, as a tribute to Edward Jenner we could call all immunizations vaccinations. Hence the use of the word today as we talk about polio vaccine and polio vaccinations. The immunization family tree included many other branches and especially the absolutely essential work, in 1948, by Noble Laureates John Enders, Tom Weller and Fred Robbins who figured out how to make polio viruses grow in the lab, making polio vaccine production possible.

It is a family tree that came to encompass Thomas Francis Jr., Maurice Hilleman, who we learn this morning died yesterday at the age of 85, an icon in the immunization field, and thousands of bench scientists, pediatricians, public health workers, educators, parents, polio pioneers and finally almost everyone.

There was also an evolution of society that provided a system of universities, higher education, research clusters to combine intellect, support, an environment of learning and ferment… and of course, there was a virus.

In 1921, outbreaks of poliomyelitis plagued America. That summer, a young politician named Franklin D. Roosevelt was vacationing with his family. After an exhausting day fighting a local forest fire, he went to bed feeling as though he had contracted a cold. In a few days Roosevelt found out he had polio.

A virus brought this nation together, with the feeling we are all in this together. It changed the nation but it also changed Franklin D. Roosevelt. James Laney, former US Ambassador to South Korea, has suggested that Roosevelt, the product of a privileged upbringing, became a champion of the poor and oppressed not because of his disability, but because at Warm Springs, Georgia he spent long periods of time with common people, poor people, and oppressed people. This made him forever their champion.

In January 1953, Jonas Salk of Pittsburgh presented the results of his tests of a "killed virus" polio vaccine on 161 children to the Immunization Committee, a scientific advisory committee to the National Foundation for Infantile Paralysis. Salk's work seemed promising to O'Connor, and to Thomas Rivers, the dean of the foundation's scientific advisers. The children had shown no ill effects and immediately, O'Connor and Rivers began planning for a major field trial.

There were endless discussions that year on how to do a trial. Thomas Francis Jr. became involved because of the high trust level that everyone seemed to have in him.  Francis indicated he would manage the field trial as early as December 1953 but before accepting the job he made sure that he had the state health officers on his side. And he also made sure that the placebo control part of the field trial would have priority for vaccine if supplies were in question.

There were problems. Some were opposed to a placebo trial. They knew the vaccine was good. To hold back the vaccine until it had been properly tested was to risk children's lives, but to release it prematurely risked infecting healthy children. They raised the question whether it was ethically right to have a placebo group and Thomas Francis simply said you can’t do science on the cheap.

The world was well served by Thomas Francis. He was dedicated, confident, trusted, and obsessive for detail. No one had ever done a field study involving 1.8 million children.

You are here because you know the rest of the story. But even knowing the story, it is hard to recall the intensity of the relief that parents got that day. They got reassurance that good science had been applied to the evaluation of the vaccine.

With Walter Winchell raising the question that the vaccine was harmful, (his words were, “in a few moments I will report on a new polio vaccine — it may be a killer!”)and the problem with Cutter vaccine two weeks later, we can now see the wisdom of that decision to pursue the field trial. But think of what it must have required in personal confidence at the time.

So this is an occasion to be pleased with the field trial, with a person who took the responsibility to make it happen, for a university that provided the opportunity and for a legacy that goes beyond that press conference.

But there is far more. We often dwell on the science that day and describe it as a breakthrough. It was… but it led, in turn, to a social breakthrough. When Mrs. Hobby, the secretary of HEW, deliberated on how the government would respond, she simply didn’t anticipate the scope of the demand for vaccine. President Eisenhower did not believe the government belonged in such things as national health insurance or in the allocation of drugs and vaccines. The administration was so aware of the strong concern about socialized medicine, that it never saw the dangers of capitalism in medical care and expected the demand for vaccine could be handled through the market place.

Mrs. Hobby came to Washington, in her words, to bury the dream of socialized medicine. She was praised by Senator Alexander Smith of New Jersey for her wise handling of the issue.

"Refusing to be precipitated into a hasty program of federal regimentation," Smith said, "Mrs. Hobby and her advisors with the full cooperation of the doctors, vaccine manufacturers, and distributors, worked out a program of voluntary distribution which promises maximum effectiveness and retains our basic American principle of non-federal control of the doctor-patient relationship."

Senator Smith’s words were premature. Because within days of the press conference at this institution, the public was shocked to find no government plan and suddenly there was not enough vaccine to meet demand. At a Senate hearing Mrs. Hobby said, “I think no one could have foreseen the public demand.”

President Eisenhower finally bowed to public pressure, reversed course and said “he was fully agreeable to a large federal role in the distribution and financing of this vaccine.”

He went on to say he did not want wealth to be the governing factor as to who would be protected.  Here is the key. Because the public became involved, vaccines went from the protection of individuals, to a social good. Three months later there was a Senate bill for federal provision of polio vaccine.

There is a direct connection from the press conference 50 years ago, the public reaction of hope, the look to government to protect all of society, even the poorest, and the history of polio elimination from this country, the interruption of measles transmission in this country, the government financed childhood immunization program and a spill over onto the global scene.

But I should first mention that Thomas Francis’ insights were not limited to polio. He was the first to isolate a human influenza virus. And it was Francis who taught Salk the basics of vaccine production. In the two years before the announcement that the vaccine worked, various people, including Jonas Salk, Dr. Weaver at the National Foundation for Infantile Paralysis and Dr. Francis, were discussing the future of the Foundation. Dr. Francis shared his thoughts in a letter to Dr. Weaver written August 3, 1953, in which he suggested the Foundation become a broad National Foundation for Preventive Medicine. He called preventive medicine the “medicine of the future.”

He expressed concern that NIH concentrates on disease and even public health talks of rehabilitation and statistics rather than, “pursuing with vigor and research the preventive areas.” He concludes that “A foundation for Preventive Medicine could furnish aid or help direct attention to a great variety of problems and from many angles, rather than working within a restricted range. I believe American Medicine wants to move. Many are tired of being only therapeutic technicians.”

Francis was the ideal… simultaneously a generalist and a specialist. As an aside, it is refreshing to see Thomas Francis Jr. spending the next weeks, after the press conference, writing letters of thanks. Letters to Edward R. Murrow, to Basil O’Connor, and to the people who had made this all possible.

But what was the next chapter of that history book? Where has history taken us over 50 years?

1. The socialization of immunization is a fact. Vaccines protect both society and individuals.
   
   
2. The eradication of smallpox from the world. It was a direct result of seeing immunization as a public good that drove that decision. If the reasoning is true for a country, it seemed true for the world, and in 1965, 10 years after the press conference, the US agreed to engage the problem of smallpox in the world.
   
   
3. A change in the rules as parents saw themselves as both protecting their children but also honoring a social contract which is part of living in this society. We are all in this together. The polio pioneers symbolize this.
   
   
4. The elimination of polio from this country. Twenty five years ago we had our last polio outbreak in this country. It involved a religious community that had not immunized as a matter of religious principal. But when they found that their children constituted a risk to others they immediately immunized their children. You see their sense of the social contract was stronger than their need to protect their children. Two weeks ago I had the privilege of meeting one of the public health nurses who gave polio vaccine to those children and helped to stop the outbreak.
   
   
5. Then, inevitably, the elimination of polio from this hemisphere and now the final lap in the elimination of polio from the world.
   
   
6. But it was the same thinking, namely a social contract and the social good that led us to interrupt the transmission of measles in this country.
   
   
7. It led us to a global immunization program for six diseases in the 1970s and 80’s.
   
   
8. And it led to a rejuvenation 5 years ago when Bill and Melinda Gates gave $750 million dollars to the Global Alliance for Vaccines and Immunization (GAVI) in order to promote equitable use of vaccine, and the provision of newer vaccines, such as Hepatitis B, to children everywhere. They anticipated that governments would quickly follow their lead but the response was lukewarm.
   
   But there is an incubation period even to ideas. This year Bill and Melinda Gates gave an additional $750 million to GAVI which Norway immediately matched with $250 million and the next day the UK announced they would contribute $1.8 billion. The idea is too compelling to not catch on.

In some ways we are making a return to the days that brought us polio vaccine with a mixture of public and private funding. It is hard to tease apart what was public and what was private 50 years ago as private gifts from the March of Dimes (from money given by the public) and public gifts from NIH commingled in both public and private research universities and labs while the private production of vaccine was purchased with public government funds.

We now see a similar situation with public NIH dollars, private Wellcome Trust Pounds and private resources from the Rockefeller and the Bill and Melinda Gates Foundation pouring into research for vaccines against malaria, tuberculosis and AIDS that will require public funding for the ultimate distribution in all countries.

Even vaccine administration in this country is a mixture of public and private clinics and purchases. I had the opportunity several weeks ago to remind 1500 public and private immunization workers how they are on the front lines of the most important foundation stone in all of public health, namely, getting safe and effective vaccines into children who will be protected for an entire lifetime. I quoted Adali Stevenson in saying “You have served society well and sometimes better than society deserved.”

What are some lessons we take to later chapters of the history book?

1. Individuals matter. Francis, Salk, O’Conner, Rivers, Weaver, Roosevelt, Enders, Weller, Robbins, polio pioneers and everyone here…Your individual contribution will ripple forward forever. Abraham Lincoln has left no biological DNA in our gene pool and yet every day we know about his contribution because his social DNA continues on forever…as does yours.
   
   
2. Coalitions matter. The vaccine could not have been a reality without an unusual coalition of public resources, private funds, the dimes of millions, universities…and on and on. Leadership in health no longer goes with a title. It goes to the person who can assemble a coalition.
   
   
3. The Generalist/Specialist perspective of seeing the whole while concentration on a part. We see this as Thomas Francis advocated for a Foundation for all of prevention even while he concentrated on polio.
   
   
4. The limitations of science. Those outside of science are often overwhelmed by a sense of certainty that appears to characterize science. Certainly the scientific approach is an attempt to be objective and strive for certainty. But certainty is the Achilles heel of science, religion and politics. As Richard Feynmann said, “The essence of science is uncertainty.” Always trying to prove that something is wrong and knowing that those things we call certain, are certain only within some range of probability. Science isn’t truth. It is simply our best stab at it.
   
   But we also learned, in the requirements imposed by Thomas Francis, the necessity of scientists seeking a moral compass. Science lacks a moral compass. Scientists must provide it.
   
   The great French physician, Rabelais, in the 16th century became expert in a dozen fields including theology, law, history, botany, literature and cooking. In his writing he has Gargantua saying in a letter to his son, what Will Durant describes as 10 words to live by: “Science without conscience is but the ruin of the soul." We have a desperate need for a moral compass.
   
   And so Thomas Francis taught us once again that there is something better than science, and that is science with a moral compass, science that contributes to social equity, science in the service of humanity. Science aimed at health for all. Science that says you can’t take short cuts.
   
   
5. We are reminded, with the long tortured history of the vaccine, that it wasn’t magic. We live in a cause and effect world. As Stephen Hawking wrote in A Short History of Time, the history of science is the gradual realization that things do not happen in an arbitrary fashion. Every step in the process was a deliberate step.
   
   You would not be here, as teachers or students, or interested citizens if you were fatalists. You are here because you saw the world change by that event and you actually think you can change the future. And you are right.
   
   
6. We have learned that vaccines, with all of the history that made them possible, are worthless…if not used. For example, after years of successfully using measles vaccine, and interrupting indigenous transmission in this country, some parents opted out. This led to an outbreak 15 years ago in which 55,000 children got measles and 123 children died. Those children could not make the choice for vaccine. They depended on their parents who let them down, thinking they were doing the right thing for their children but so afraid of autism and other problems not demonstrated to be associated with vaccines that they withheld this life saving procedure…and they can never go back.
   
   We have now seen children crippled in Nigeria, because religious leaders in Northern Nigeria became the modern Walter Winchells and scared parents from using the vaccine for 10 months…with the inevitable outbreaks and spread to other countries.
   
   We aren’t doomed by fatalistic forces. We are doomed by not exercising our ability to make wise decisions, to solve problems, to use the information available, and in the words of Jonas Salk, to make evolution be what we want it to be.
   
   
7. We are reminded once again that the solution is not to “Think Globally, Act Locally.” It is to “Think and Act, both Locally and Globally.”
   
   
8. We are told countless times “Do no harm.” It is the first rule of medicine and public health. It is repeated with frequency during training and almost always misses the whole truth by concentrating on half of the problem, focusing on errors of commission. My supervisor, when I left for Africa the first time 40 years ago, startled me on parting when he said, in an off hand manner, “By the way, you will never forget the people you kill.” It took me some years to face up to the fact that I would forget them because far more people are hurt and killed by our errors of omission than by our errors of commission. They are the people hurt because we did not apply our knowledge. The people who did not get vaccines or share in the benefits of our science and our knowledge and our experience. The field trial was one step but then the vaccine had to be made available to everyone. Because as Primo Levi reminds us that once we know how to prevent torment and don’t do it, we become the tormentors. It was knowledge of the harm of omission that caused Thomas Francis to advocate for a Foundation for Prevention.
   
   
9. We learned again that if you want to do important things, work on important problems.
   
   
10. And finally…The power of optimism - Harlan Cleveland developed an interest in public health and global health late in life and says the field is fueled by “unwarranted optimism.” It is optimism that allows us to go beyond what seems to be possible. It was optimism that drove that field trial.

In April 2055 – There will be another celebration at this University, to remember the centennial of the announcement. I won’t be here…although I intend to try…but there are some people in this audience today who will be here.

And someone, in giving the Thomas Francis lecture, will describe the true legacy of the 1955 press conference. They will point out what in 2055, a hundred years later, is simply accepted, namely that the place or country of birth, ethnicity, the wealth of parents, the education of the family will no longer be the deciding factors which determine whether a child is protected or not protected by vaccines. Because the legacy of a 1955 field trial, a US government decision to make resources available for the use of polio vaccine for all children, the elimination of smallpox and polio from the world, the promotion by Bill and Melinda Gates for more vaccines, safer vaccines, and equitable distribution of vaccines, and a hundred other steps, will have led to a world where this is an accepted part of global conventions.

In the words of Richard Horton, Editor of Lancet, we will have discovered that equity is as precious as any drug or vaccine.

And even given the enlightened approach to global health that finally became the norm, those gathered will still express their astonishment over the number of vaccines given. Dozens of vaccines will be part of the standard childhood immunization program.  An additional computer-generated array of various other vaccines will be given to children, determined by a scan of their genome disk. They will include vaccines against infectious diseases, cancer, and chronic diseases. What will be reiterated is that vaccines are the very foundation of public health providing inexpensive, safe, life-long protection.

But 100 years later they will still marvel at the audacity of a field trial that kept track of 1.8 million children before the days of computers.

And the speaker will say it was just a moment in time. But you will have learned the lesson. Every moment in time ripples on forever and that moment in time changed the world. It allowed the expected lame to walk and it ushered in the expectation that not only will government support the search for new knowledge and the sharing of that knowledge, but it will also mold the tools of that knowledge into effective immunization programs.

Those vaccines, as they go into children around the world, will carry messages that instruct immune systems on how to serve that person better. And every message will carry the social DNA of Thomas Francis, Jonas Salk and the University of Michigan.