Medicine Makers of History: Salk and Sabin - The Medicine Maker
Polio has returned to the United States of America.
In New York state's Rockland County, one person tested positive for the disease on July 21, 2022. Two weeks and one day later, the polio virus was found in samples of New York City wastewater.
Meanwhile, in the UK, a striking headline broke on August 10: "All children aged 1 to 9 in London to be offered a dose of polio vaccine."
The decision came from the UK's Health Security Agency, and was in response to a slew of detections of polio in London wastewater. As in New York, these traces are most likely derived from individuals who had recently received oral polio vaccines (OPVs), which use a live version of the virus that has been shown to cause one case of disease per 2.64 million doses.
A report from GlobalData shows just how much the news from the two Anglo-Atlantic countries has spiked Twitter discussions around polio. A range of vaccine thought leaders from scientific institutes – including the ex-Microsoft magnate himself, Bill Gates – have weighed in on #polio.
Because polio can be transmitted via fecal matter, traces of the disease in sewage pose a risk of creating new cases in countries where polio is considered eradicated. Recent declines in vaccination rates in some of these countries only amplifies the danger.
The frequency of polio detections is one reason for the British authorities' vaccine push, but another is a low vaccination rate. London is the lowest-performing region in the UK for polio vaccinations, with just 86.7 percent among children vaccinated before their first birthday during 2020–21 period.
The WHO target for overall vaccination rates is 95 percent. In 2010–11, England sat much closer to this figure at 94 percent. Since then, it has dropped to 92 percent. Northern Ireland also falls short at 94.5 percent, whereas Wales and Scotland are faring better at 95.6 and 96.5 percent respectively.
In countries such as the US where polio is no longer active, health authorities prefer or strictly use inactive "killed virus" polio vaccines. As of 2019, every country in the world either uses the inactivated polio vaccine (IPV) or a combination of IPV and the OPV, the latter of which remains in use despite its inherent risk thanks to certain advantages it offers in cost and immunity.
But why are there two forms of polio vaccine at all? The answer leads us back to two 20th-century scientists, Jonas Salk and Albert Sabin. Salk is the man behind the IPV and also the now-prestigious Salk Institute. Sabin is the name behind the live vaccine and, though his legacy is on the wane, there was a time when his oral vaccine was the dominant option.
The great race that ensued between Salk and Sabin makes for quite a pharmaceutical drama – and one a little more personal than the far more recent race between Pfizer, AstraZeneca, Sinovac, and others to produce a world-beating COVID-19 vaccine. So, why not take a look at the two men and their dueling vaccines? Perhaps we'll learn something.
Jonas Salk was a New Yorker born to two Russian Jewish parents in 1914. With no privileged upbringing to see him through, he graduated from the City College of New York with a Bachelor's in chemistry in 1934. From there, he progressed to New York University Medical School, where his desire to help humankind (rather than individual patients) led him to lab work. Postgraduate research took him on an elective to the University of Michigan, where he discovered the type B influenza virus and later worked on a project to produce a flu vaccine for the US army.
In 1953, he made a slightly unorthodox move, opting to vaccinate himself and his family in his own kitchen after boiling the needles and syringes on his stovetop.
In 1946, Salk got his own lab at the University of Pittsburgh School of Medicine. Two years down the line, he was asked to conduct research on polio by Harry Weaver, the director of research at the National Foundation for Infantile Paralysis, which was set up by none other than the US's most famous polio patient, President Franklin D. Roosevelt.
In 1938, the Foundation launched a polio treatment fundraising campaign named the March of Dimes. The March's presidential push was a matter of some urgency, coming at a time when tens of thousands of people were contracting polio each year. Its call for charity successfully mobilized the masses into making a cumulative flood of small donations, which Roosevelt himself said were "mostly from children who want to help other children get well."
Three years after Roosevelt's death, Salk took up the Foundation's offer. First, he directly researched polio; then, he started work on a vaccine. Salk chose to work on a safer "deactivated" virus, rather than the then-standard live form. In a move that jarred with the scientific orthodoxy of the time, Salk grew samples of the virus and applied formaldehyde to block its ability to reproduce.
In the summer of 1952, tests of Salk's "killed virus" vaccine on animal models proved successful and he moved to testing the vaccine in children. In 1953, he made a slightly unorthodox move, opting to vaccinate himself and his family in his kitchen after boiling the needles and syringes on his stovetop. That year, he announced the initial human tests as safe on national radio, and 1954 saw massive field trials in which 1.8 million children were vaccinated nationwide using a new and now-standard double-blind placebo method. In 1955, the vaccine was declared to be safe, potent, and 90 percent effective in protecting against polio. Salk's vaccine was adopted for use in the US, with six companies, including Eli Lilly; Cutter Laboratories; and Parke, Davis and Company handling the manufacturing using facilities guaranteed by March of Dimes funding.
These mid-to-late years of the 1950s saw a huge push from the March of Dimes, in which advertising by the likes of Mickey Mouse and Elvis Presley helped raise both awareness of and funds for Salk's vaccine. Salk, too, became a beloved public figure, but was not interested in using his fame to become wealthy. In a 1955 broadcast of the current events television program See It Now, Salk was asked who owned the patent to the vaccine. His answer, whether intentionally or not, was iconic. "Who owns this patent? Well, the people, I would say. There is no patent. Could you patent the sun?"
Picking apart this response leads to a few interesting finer points.
First, it should be noted that the National Foundation for Infantile Paralysis' lawyers did, at one point, investigate whether a patent would be possible and determined that it would not. It is true that neither Salk nor the Foundation pursued opportunities for property or profit by other means, but it is also true that, in the case of the polio vaccine, this door may never have been open in the first place due to the legal technicalities of the time.
Second, it is also worth noting that the vaccine's production had already been funded by the March of Dimes – by the American people themselves. For Salk's vaccine, there was no need to recoup the costs of research, development, and distribution using conventional commercial means. By extension, it also meant that any current or future global rollout of the vaccine would in effect serve as an inexpensive "gift" from America to its allies – quite on-brand at a time when US investments were rebuilding many European and Asian economies wrecked by World War II. Some European countries imported the Salk vaccine directly from the US, whereas others, such as Sweden, manufactured the vaccine in their own state facilities.
But the story does not end here, because Jonas Salk and his vaccine had a rival.
Like Salk, Albert Sabin had eastern European Jewish roots. He was born with the name Abram Saperstejn in 1918 in Białystok, then part of the Russian Empire and today one of Poland's largest cities. At age 12, upon immigrating to New York, his name was anglicized to Albert Bruce Sabin. He also received his initial medical education in the Big Apple, but became much more of a globetrotter than Salk. After returning from a year of study in London, Sabin began a fellowship at the Rockefeller Institute for Medical Research, where his interest in poliovirus began. Interim service in the US Army Medical Corps saw him switch focus to vaccines for insect-borne diseases such as encephalitis and dengue as he took on assignments all over the war's various theaters in Europe, Africa, the Middle East, and the Pacific.
At the war's end, Sabin took a job at the University of Cincinnati College of Medicine. Here, he returned to studying polio and, following fruitful research, began work on an oral, live-virus vaccine. He eventually landed on three mutant strains that seemed to prompt antibody production without inducing paralysis. Just like Salk, Sabin tested his vaccine on himself and his family before moving on to other groups of limited size.
But when it came to scaling up his trials, Sabin ran into a problem. Salk had beaten him to the punch and there was no longer any support or perceived need for massive US trials of a new vaccine. Undeterred, he looked to make headway overseas by setting up a long-term collaboration with Soviet virologist Mikhail Chumakov. Together, they worked to perfect the oral vaccine and, from 1955 to 1961, it was tested on 100 million people across the USSR, eastern Europe, Singapore, Mexico, and the Netherlands. This opened the door for testing and licensing in the US and the vaccine's eventual validation and adoption by the World Health Organization.
In 1962, another Cold War opponent of the US, Cuba, took on Sabin's vaccine. Three years after taking power, Fidel Castro's regime became the first national government to launch a polio eradication campaign. Using the Sabin–Chumakov vaccine, Cuba effectively brought polio down from annual numbers in the hundreds to a total of 10 confirmed cases between 1963 and 1989.
Polio can be spread by fecal matter and, in the UK, that is not good news. Recent emergency guidance from England's Environment Agency allowed companies exemptions from wastewater treatment and dumping regulations, pointing to supply chain failures resulting from Brexit: "You may not be able to comply with your permit if you cannot get the chemicals you use to treat the effluent you discharge because of the UK's new relationship with the EU."
The guidance was put in place in September 2021 and withdrawn in January 2022. In October 2021, the UK parliament voted against a motion that would have required the privatized water companies of England and Wales to cease pumping waste into rivers. Representatives of the UK's Conservative government defended their decision by arguing that these companies cannot afford the infrastructure upgrades necessary to avoid the need for dumping without raising consumer prices.
In Scotland, where water is publicly owned, the problem appears less severe, but is being badly exacerbated due to climate change-induced heavy rainfall that overwhelmed much of the sewer network in 2020 and 2021. As is the case south of the border, the upgrades to infrastructure and regulation necessary to fix the problem are anything but cheap.
Northern Ireland, too, faces similar problems. Long-term underinvestment in its publicly owned sewer network has led to sewage dumping, which has damaged the country's waterways. In 2018, roughly two-thirds of Northern Ireland's rivers and three-quarters of its lakes scored below "good" in pollution rating. By 2021, every single body of water in Northern Ireland scored below "good."
Rising sewage spills across the UK will ultimately mean that more people come into contact with polluted water. If it contains traces of poliovirus, the unvaccinated will be at greater risk – and we could potentially see cases of the disease return to Britain for the first time since 1984.
It wasn't just international numbers that let Sabin turn the tables on Salk. There was also a tragic episode known as the "Cutter incident," named after the aforementioned Cutter Laboratories. An error at the company resulted in a batch of 120,000 doses containing a live polio virus. Tens of thousands of children were infected, 56 were paralyzed, and five died. A knock-on epidemic then occurred, paralyzing 113 more people and killing another five.
The Salk vaccine also ran into a purely logistical supply problem. Put simply, the US federal government had not built up a stockpile. In fact, when Salk's vaccine was approved, the Eisenhower administration had not a single injection ready for use. The buck was passed back to the National Foundation for Infantile Paralysis, who had a total of nine million shots – not even close to enough for a full-scale national campaign.
Meanwhile, the Sabin vaccine's rollout overseas put another dent in Americans' confidence in the Salk vaccine. Politicians wanted to know why Soviets and foreigners in the tens of millions were receiving an American vaccine that appeared to be safer than the domestic option. In 1961, a petition by US pediatricians prompted the American Medical Association to recommend that the Sabin vaccine replace the Salk vaccine.
The Sabin vaccine didn't win out simply because of its rival's unforced errors. One major draw was its low cost. Just like Salk, Sabin had refused to take out a patent on his vaccine, saying, "A lot of people insisted that I should patent the vaccine, but I didn't want to do that. It's my gift to all the world's children."
Additionally, Sabin's oral vaccine produces a better immune response. It induces both systemic and intestinal immunity, the latter of which prevents transmission of the virus to others. This and the lower price help explain why use of the Sabin vaccine is often the preferred strategy in less wealthy countries where the disease remains in wild circulation.
Last, but not least, the oral nature of Sabin's vaccine renders it far easier to administer, especially among children. Though the vaccine itself was not exactly a delicious treat, this was resolved at no great cost by "serving" it to children on a lump of sugar. In fact, this workaround has a cultural legacy that shows up in the 1964 movie Mary Poppins.
One day, during the songwriting process for the movie, the son of Walt Disney songwriter Robert Sherman came home and told his father that he had received the polio vaccine. Sherman asked if it had hurt, but his son reassured him that the vaccine had not hurt at all – in fact, it had been served to him on a lump of sugar. This pushed Sherman and his songwriting brother Richard out of a minor writers' block and the resulting song (if you haven't guessed it yet) was A Spoonful of Sugar (Helps the Medicine Go Down).
From there, it appeared to be game, set, and match. Across the 1960s and 1970s, polio vaccinations became the norm in high- and middle-income countries and, in everywhere but certain states in northern Europe, national governments used the Sabin vaccine. In 1988, the World Health Organization launched a major push to eradicate polio worldwide. During this push, Sabin's oral vaccine continued to hold sway.
It wasn't until the 1990s that debate began to swing back in favor of the Salk vaccine. Polio had now become so rare that, often, its occurrences were due only to the live nature of the Sabin vaccine (as seen in London today). Both vaccines remain in use, but it's now more or less settled that in an ideal post-polio world, the Salk vaccine should dominate.
Let's first suppose that our criterion for victory is the number of people treated. Here, we could argue that Sabin and his vaccine won the short-term headcount by taking the lead in vaccinating the world during the mid- to late 20th century, but we can just as easily argue that Salk should win because his vaccine is best-suited for finalizing and maintaining our "post-polio" world.
Free of obligations to shareholders and corporate rationale, each man was perfectly at liberty to say, "No, thank you; I don't want to patent this."
Instead, let's suppose that our criterion is fame. Salk probably wins here thanks to his eponymous Institute but, for the sake of balance, I'll add that countless millions could easily hum the Sabin-inspired A Spoonful of Sugar, whereas – if we are being honest – relatively few are familiar with the Salk Institute.
Ultimately the question of whether Salk or Sabin "wins" is a false dilemma. There can be other winners, too. You and I are winners, because we live in a world where polio is no longer an ever-present threat. For creating this world, both Salk and Sabin deserve ample credit – for their hard work and for their prioritization of long-term collective human wellbeing over transient bank account boosts.
Free of obligations to shareholders and corporate rationale, each man was perfectly at liberty to say, "No, thank you; I don't want to patent this." We should consider the material conditions that gave Salk and Sabin this freedom. Individual men might turn down opportunities for personal profit but, ultimately, scientific research, production, and rollout are not free. From lab wages to chemical ingredients to petrol, the costs are ever-mounting and, by one means or another, those costs must be covered.
Salk's vaccine was funded by ordinary Americans' donations. The March of Dimes was a charity but, with ample support and promotion from both the government and private enterprises (how many causes have had Elvis, Mickey Mouse, and the leader of the free world behind them?), it won so much broad support across society that even the dime-sized donations it was named after scaled up into a formidable polio warchest. Combined with Salk's refusal of a patent, this national, noncommercial, voluntary effort brought into existence a vaccine that helped not only US citizens, but also people in other countries on America's side of the Cold War. Further down the line, Salk's vaccine became the world standard.
Salk's vaccine departs from the capitalist model, but Sabin's departs from the capitalist world entirely. Though he began his work in American academia, Sabin's choice to collaborate with Mikhail Chumakov moved the development of this vaccine behind the Iron Curtain. The successful Soviet development and eventual transcontinental rollout of Sabin's vaccine makes for an interesting episode in US/USSR scientific rivalry, but it also makes for an interesting compare-and-contrast with Salk's vaccine. Both were funded publicly, but one through a bottom-up accumulation of voluntary donations and one through a top-down direction of state resources.
We may choose to note here that the Salk vaccine ran into logistical problems and the shocking Cutter Incident, whereas Sabin's Soviet rollout seems to have been a less fraught affair.
Early in this piece, I mentioned that the COVID-19 vaccine race was far less driven by individual scientists than its polio-focused counterpart. Though the public funding and non-patenting of the polio race might also seem a pure and perfect opposite to the corporate branding and IP-controlled regional rollouts that we associate with the push for effective COVID-19 vaccines, a close look reveals certain parallels:
- National governments: Salk's vaccine had US government support via Roosevelt's March of Dimes and Sabin's vaccine was completed under a state-socialist system. But Pfizer's vaccine received massive state support too, from Operation Warp Speed in the US to German federal backing of BioNTech. Sinovac was produced by Sinopharm, a vast company that lies somewhere between the private and public sector under China's state-owned enterprise model.
- Spheres of influence: Salk's and Sabin's vaccines both went global in time, but not before their initial rollouts drew a very clear dividing line. NATO and NATO-adjacent countries went with Salk, whereas Soviet-aligned and non-aligned countries went with Sabin. The COVID-19 vaccine rollout paints a similar picture. Vaccines developed in America and Europe went primarily to countries in those regions, whereas Chinese and Indian vaccines were sent by export and donation across the global south to less wealthy countries less aligned with the US and its allies.
A famous thinker once wrote that history repeats itself first as tragedy, then as farce. On one hand, we can see this very clearly in polio, a 20th-century crisis that was quashed by human endeavor and reason, only to rise from the grave into the black comedy of the 2020s thanks to declining vaccination rates and long-term underinvestment in sewage management systems. But on the other hand, in the COVID-19 vaccine, we can see history repeat itself in a much more positive way. For all its warts and iniquities, the COVID-19 vaccine rollout saw citizens, governments, institutes, and enterprises take rapid action to defuse what could have been a far worse public health crisis. It's precious proof that the age of public goods and collective visions that Salk and Sabin lived in is not yet over, that communication and coordination are still possible, and that there are still things to believe in beyond our own narrow personal gain.
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