Medicine Before the Vaccine: A Review of Polio Wars

In an era before vaccination against polio--which has chased the paralytic form of the disease  from all but 2 countries--care for those afflicted with the dread disease was paramount. That care was severely hampered by a lack of understanding of all the facets of polio including that it is a gastrointestinal virus which causes paralysis only in rare cases. At that time bed rest, splints, and orthopedic surgical procedures were part of the routine care administered to a patient. 

To a person reading this in 2015, bed rest should sound like a foreign concept as anyone suffering with a paralytic condition caused by, for example, a stroke is basically overwrought with visits from physical medicine and rehabilitation physicians (physiatrists), physical therapists, and occupational therapists who work diligently with the patient in the hope of regaining function as well as learning to accommodate any permanent dysfunction.

It is hard to imagine it otherwise, but it was.

In Polio Wars: Sister Kenny and the Golden Age of American Medicine Yale University historian Naomi Rogers provides an exquisitely detailed and scholarly account of how an Australian bush nurse took America, in the decade before the Salk vaccine, by storm and crusaded to change how polio was treated and conceptualized in the face of fierce opposition by the medical establishment. At one time, she was the most admired woman in America and the subject of a Hollywood biopic. 

Reading the book one is immersed in the world of American medicine in the 1940s and 1950s where physicians held a special status that, I believe, has eroded into the Burger King Have-It-Your-Way style of medicine of today. Physicians forcefully debated, physicians voraciously read, and physicians meticulously thought. While life in such rarified air might be refreshing to read about for physicians, especially when they are today deluged by complaints from patients doggedly pursued by administrators who care little for whether a medical decision was correct or not, the downside was a recalcitrance by some to pursue therapeutic leads if their pedigree was lacking. Such was partially the situation with Elizabeth Kenny and her efforts to improve the care of polio patients. 

While Kenny, who may have lacked a full understanding of the pathophysiology of polio, clearly seems to have embellished and exaggerated the results of her work, which was centered on early mobilization, treatment of muscle spasm, and retraining of muscles (some of which had been advocated pre-Kenny) her intransigence was admirable and her battles with the well-connected and powerful instructive as well as instrumental to the professionalization of the field of physical therapy and highlighted the important role of physical medicine and rehabilitation physicians.

New Rabies Strain Still Can't Create Zombies

A sadly common question I get asked too frequently is "What virus can turn someone into a zombie?" The answer is that no virus can turn one into a zombie anymore than it can turn one into unicorn. However, if I were to name a disease that causes a person to behave in a manner that might be zombie-like, I would say it is the illness caused by the bat-borne rabies virus. For a great historical treatment of the mystique surrounding the illness see Rabid: A Cultural History of the World's Most Diabolical Virus.  

Rabies is a disease that evokes, to those who are familiar with it, fear and was an infection that the great Louis Pasteur trained his genius mind on to formulate a vaccine: the subject of my favorite children's book. In the US, just two human cases occurred in 2010 and most animal cases are in wildlife, though it is important to remember that cats are one of the more common domestic species to contract rabies (see this video of a zombie-like rabid cat). Once infection has set in, only 5 people are known to have survived despite the Herculean Milwaukee Protocol that has been developed in recent years. Rabies in humans, because of its severity and transmission characteristics (blood/body fluid) in humans it is rarely transmitted human-to-human, though organ transplantation is one potential route. 

So with the news of a new rabies strain being found in New Mexico is there a possibility that this could be akin the rage virus of 28 Days Later fame? 

Not a chance.

New lineages of viruses evolve naturally and rarely confer wholly new transmission characteristics. What is likely is that since the ultimate reservoir for rabies are the exceedingly prolific bat species, we know only a small fraction about all the strains of rabies that circulate amongst them. This poor rabid fox likely came into contact with a bat and acquired the new strain providing an opportunity to study the virus.

Sorry to disappoint but no zombie apocalypse in the offing...yet. 
 

Dressed Down by the Captain of the Men of Death (Again)

The bacterium Streptococcus pneumoniae or the pneumococcus was labeled the "Captain of the Men of Death" by Sir William Osler because of its extreme prowess at killing. Today we are fortunate that the availability of pneumococcal vaccines has diminished the burden of invasive pneumococcal disease but it still causes approximately 3500 deaths per year. Those with the bacteria in their bloodstream succumb to the infection in 15% of cases--a figure that is thought not to have improved for decades despite myriad improvements in critical care. 

In my career I've taken care of several patients with severe pneumococcal infections and each time I am astounded by its deathly abilities. Last night, I unfortunately saw pneumococcus in action once again in a cirrhotic patient (who I don't believe was vaccinated).

There's a concept in treating patients with septic shock known as decompensation. Human physiology can hold out for so long and then, the deluge. Once decompensation occurs, it becomes a Herculean task to counteract the derangements induced by the infection, which soon become irreversible, and maintaining a blood pressure can become near impossible.

Pneumococcal vaccines, a life-saving technology developed by Dr. Robert Austrian, have the ability to make these types of occurrences a remnant of the past but if only if we avail ourselves of their benefits. For in those unlucky individuals in whom severe pneumococcal sepsis ensues, to rescue them requires beating back the devil.

The Dog Gave Me Plague

The recent detailing of the 4-person cluster of plague cases that occurred in Colorado in 2014 is a fascinating look at how plague, in the modern age, can still cause substantial morbidity. 

People forget that plague is endemic in parts of the US that are west of the "plague line" and we have a handful of cases each year in the US. What was special about this cluster was the involvement of a dog and possible human-to-human transmission in one instance. Additionally, half of the cases of pneumonic plague were mild and didn't require hospitalization, a fact that calls into question the common conception of plague as a universally severe illness.

The index mammal in this outbreak was a dog who was euthanized for an illness that caused bloody-tinged cough. This was subsequently diagnosed as plague and the property on which he lived had inactive prairie dog burrows and rabbits--known means for how the dog may have acquired its fatal affliction.

Didn't realize there was a movie with this title, unfortunately its anti-vivisection.

What happened next illustrates the concept of One Health, an approach to medicine and public health in which animal and human health issues are integrated, perfectly: 3-4 contacts of the dog became ill with plague. Of the 4 human cases, 3 had very close contact with the ailing dog and the remaining patient had some contact with the dog but also close contact with the dog's owner, raising the prospect that human-to-human transmission occurred--a phenomenon that hasn't occurred in the US for 70 years.

So, it's time to add spreading plague to the long litany of things, including their favorite pastime of eating homework, to blame on dogs 

Understanding Ebola in West Africa Through Laurie Garrett's Lens on Kikwit

The WHO announced yesterday that the decline in Ebola cases which has been occurring has halted. This is ominous news as it highlights the very real fact that unless every Ebola case is run down, a new transmission chain can commence, reigniting the epidemic in West Africa. 

To understand why the West African Ebola epidemic is so recalcitrant to the public health measures that have been employed to stop all the prior instances of Ebola, it is instructive to examine prior outbreaks. After the 1st outbreak of the most virulent Zaire strain of the virus in 1976, the next biggest outbreak of this strain (present outbreak excluded) was in Kikwit (DRC) in 1995.  This--once considered large--300+ person 1995 Ebola outbreak has many lessons for today, as presented in a book published in late 2014 by Laurie Garrett. Ebola: Story of an Outbreak, extracted from Garrett's Betrayal of Trust: The Collapse of Global Public Health (with a new introduction focused on the West African outbreak), provides an in depth view of the Kikwit outbreak highlighting the struggles that physicians, many of whom are now everyday names in infectious diseases now (e.g. Ali Khan, Pierre Rollin, David Heymann), encountered in trying to extinguish this outbreak.

Many of the incidents described presage what occurred in West Africa: distrust of government authorities, belief in a mystical origin (which includes a special hippopotamus), graft, corruption, and intense press coverage. The lesson I found most instructive is that after the outbreak abated, within a couple of years, public health infrastructure and public health behaviors had again eroded to dangerously low levels. Such a devolution illustrates that resources infused from outside are effective in the short term, but are not sustainable without actual acceptance from the local population as a rapid regression to the mean takes place. For example, safe burial practices ceased, the etiology of Ebola was placed back in the supernatural realm, and an ambulance became a limo for a local government thug. This regression to the mean is occurring even more rapidly in West Africa where, while the disease still rages, lax public health practices by local populations have given rise to a shadow--and open--epidemic that continues to burn.

 As someone who was captivated by Garrett's The Coming Plague and who also enjoyed I Heard The Sirens Scream, I highly recommend this book as an important guidepost to understanding the challenges faced in West Africa.