'Poverty Keeps Us Vulnerable To Diseases Like Polio'

Just a few days ago, world leaders at the World Health Summit in Berlin contributed $2.6 billion to end polio. India has not seen a case of polio since 2011, and has had successes like a sound polio vaccination programme, but the challenge of maintaining eradication efforts remains. To understand this battle and what lies ahead, we spoke with Mathew Varghese, senior consultant and Head of Department of orthopaedics at St. Stephen's Hospital in Delhi, where he runs the last polio ward in India.

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Edited excerpts:

How do you view the battle against polio so far, as someone who's been treating polio and its outcomes like paralysis, and what are we dealing with today?

When I was in medical school, we never thought eradication of a disease like polio would be a reality. That it is a reality today is thrilling and also humbling, to see how science can change the world for the betterment of humankind. That's fascinating, that we can do things once we are determined to. So, I feel good about it.

How do you see this clinically, in terms of what India has achieved and what we've learned from our polio vaccination efforts?

The history of polio vaccination is also a very important learning milestone in the development of vaccines. In the 1930s and 1940s, the United States and Europe were reeling under various epidemics of poliomyelitis. People were desperate for some treatment, some vaccine--exactly how people were desperate for some treatment or vaccine with Covid-19. It's almost parallel.

But at that time, medicine, technology, genetics research, laboratories, and understanding of the epidemiology of diseases was not as advanced. We were in the learning stages. The first polio vaccine trial, which happened in the 1930s, was a total disaster, with many, many casualties. From there, we moved on to the Salk vaccine trial for the injectable vaccine, and after that came the oral, or Sabin, vaccine developed in 1956. Again, it was a lesson in international cooperation. The trials were done in Russia. Today, there is a war situation. But then, international cooperation when people were worried about a disease, helped eradicate a disability in human beings.

I deal with polio patients today also. Just yesterday, my operation theatre saw a patient with residual deformities and paralysis of poliomyelitis. The only difference is that, till a decade back, I was dealing with children who had poliomyelitis. Now, all of them have grown up and I deal with adults with poliomyelitis. They are, however, all paralytic poliomyelitis patients and the challenge is they are more difficult to treat. Surgeons' understanding for dealing with these cases actually has diminished substantially, so when a patient is referred to a hospital, they don't know how to deal with it. Those are issues that we need to understand.

[We must also understand] the whole process of evolution of the polio vaccine. For example, after the Salk vaccine was introduced, American cases had dropped by 85%, a huge reduction. Subsequent reductions, however, were not brought about by total vaccination, but by economic development, safe water supply and sanitation. All three contributed to eradication of polio, both in the US and in Europe, not large scale vaccination that was done [later]. There are learning points here.

The reason that you, as an orthopaedic surgeon, are dealing with polio patients is because the key impact of the disease is on the legs and hands, right?

Yes. Predominantly, polio affects the legs first, then the hands, and also the spine. Usually, if you have arms and legs getting paralysed by the virus, the paralysis has ascended to respiratory muscles and then patients need an iron lung. In fact, ventilators were invented because of the need for the iron lung in poliomyelitis patients. Just look at that. For Covid-19, we needed ventilators. And those ventilators were created because of the ventilatory support required for polio patients with paralysis of the lungs. These are the parallels between polio and Covid-19. Of course, there are huge differences. But the suffering of the public at large was very, very similar.

You pointed out sanitation. Is that because of faecal-oral transmission of polio?

Absolutely. Somehow, we have to break the chain of transmission. A person that is infected can carry the polio virus in the intestine. A majority who have the infection just have a common cold or flu-like symptoms, without any serious consequences, to again draw parallels with Covid-19. It's only a small number that have paralysis. But the ones that do not have serious paralysis may be excreting the virus; thus, it is in the sewage. A child can then get it from flies sitting on contaminated faeces, then sitting on [uncovered] food items being sold.

You talked about sanitation progress, economic progress, and of course vaccination, and that the former actually had a greater role to play. So conversely, why are we seeing these polio cases in Afghanistan, Pakistan or Mozambique? Is it because children there are not vaccinated, or is it these other factors that you mentioned?

I think all factors contribute in these countries which are poor. In fact, I treat poverty as a disease. The primary problem is poverty leads to malnutrition, poor sanitation, lack of access to safe water. Therefore, malnutrition makes you vulnerable to diseases. Unsafe water makes you vulnerable to diarrhoeal diseases and all other faeco-oral related diseases. So I treat poverty as a disease, and we need to treat it.

You may eradicate polio with a lot of vaccines and technological inputs, and with billions of dollars being pumped in by the Rotary, the Bill & Melinda Gates Foundation, governments at large, the Centers for Disease Control and Prevention, UNICEF, World Health Organization, all pooling their efforts together, but you've tackled one disease. We have eradicated only one disease in the history of medicine so far--that is smallpox. Polio is [almost] there. The final bit is a difficult part so we need to work hard on all fronts.

You mentioned that you've seen patients today and operated on patients yesterday. These are adult patients who contracted polio before it was eradicated, but are still dealing with the symptoms and after effects of the disease. Why are they coming to you so late?

Again, poverty is a huge contributor to this, and also the fact that they give up. We have to understand that the poor do things out of compulsion. The rich have choices, can go to a hospital and access good healthcare, but the poor try within the limits of their resources.

For example, this patient came to me from Jharkhand. If he's come from Jharkhand, he has taken a train journey all the way [to Delhi]. He's a married man with family back home. So if he is a daily wage labourer, how does his family survive without an earning? He doesn't get his earning if he's a hawker and doesn't go out to work for the day. They try within limits of their resources and capabilities; then they give up.

When you really go into the details of what happened, of why they gave up, you'll find that they would have gone to a public hospital, would have been given a date for surgery, maybe given a date for investigation, so they had to come on another date for investigation, then again for anaesthesia checkup, then again for surgery but there was no bed vacant because beds were occupied by road traffic injury victims. Each visit was one day's wage gone, and no social support system takes care of that.

The government does a lot of things, a lot of programmes. But these are human capacity problems. How much can they take on, how much can somebody support? If neighbourhood expertise is not available, they travel a long distance. Why does the All India Institute of Medical Sciences (AIIMS) have a crowd of poor people parked outside on the pavement? That's because the expertise that is there at AIIMS is not there in your district hospitals, or your state and regional hospitals. More AIIMS are now coming up all over the country, which is a good thing. But unless you have the capacity in those AIIMS too, you will continue to have people flocking to places where there's a niche expertise, like polio surgical expertise in my centre.

How many adult polio patients, the kind you've just operated on, are there across India at this point of time?

My 16-bed ward always used to be full. Patients would call regularly, asking if there was a vacant bed. Today, post-Covid, things have changed completely. I am a little apprehensive about this. Is it because they're afraid of coming to a general hospital, catching Covid-19 and facing the consequences? Or is it that they have lost their source of income? I did a survey during Covid, talking to persons with disability and finding out what has been the impact on their families. The number one impact was the loss of a job and worry about the next meal. So, that could be why [polio patients] aren't coming.

I have beds vacant now but the patients are out there. I know that, because in the 1990s when I joined the hospital, there used to be 3,000 new cases annually of paralytic poliomyelitis in the city of Delhi alone. It was guesstimated that all over India, there were 50,000 new cases annually. But I haven't operated on 50,000 cases, which means all of them are out there somewhere, with varying degrees of paralysis. Many of them have accepted their disability and live their life. I ask those who do come, why they didn't come earlier. Typically they say 'Sir, we didn't know', or 'It was difficult for me to come because I would have to leave my family and I couldn't do that'.

What percentage of paralytic poliomyelitis cases from maybe a decade or two ago, can be cured, and to what extent?

A majority. Of course, there'll be about 10, maybe 15 patients who will need to be on a wheelchair for the rest of their lives. But even there, I can do something to [improve] their quality of life. I still remember a patient was brought in from Kashmir. He could not even turn in bed, or transfer himself to a wheelchair. I examined him and told him I could make a small change in the capacity of his daily activities by doing some tinkering with his upper limb muscles, and that these changes in the upper limb muscles might help him transfer himself to a wheelchair and use his hands better. I did surgeries on his hands and his arm.

The next time I was in Kashmir, some other patients of mine told him I was in Srinagar, at the Sher-i-Kashmir Institute of Medical Sciences, doing a workshop for training doctors on clubfoot. He landed up there with his whole family, and brought a shawl, walnuts and almonds for me. He said he could not transfer himself to a wheelchair earlier, but now he could. He could not hold a cell phone and talk, he had to place it somewhere, get somebody's help and then talk. Now, he could hold a cell phone. These are life changing things which you can do, [even if the patient] may not be able to walk. However, for the majority of them, the only goal they and the parents also have is, 'when will my child walk?'. That is their concern.

As you look ahead now, with all the learnings and the synergistic developments that polio contributed to Covid-19, how do you see your task now, not just as a practising doctor, but also as someone who's contributing to the public health dialogue? What are the things that India should be focusing on?

Even today, we are learning from polio. For example, the vaccine-derived poliovirus type 2. If the type 2 virus paralysis spreads in India, that could be catastrophic, because large scale immunity against that would be very low. We need to understand what are the strengths of a population, what are the weaknesses, and address those weaknesses.

For example, the poliovirus genome [was sequenced] in 1970s, after many years of the virus being identified. The vaccine was generated before the genome was identified. With Covid-19, technology was so advanced that we could identify the genome within [three months]. ... the epidemic in Wuhan [started in] November, the genome was published on a public site in January. Can you imagine? In three months, a genome was identified and put up for public use, so that whoever wants to do further research on this, generate vaccines or do whatever, it's possible. Technology has made us that much closer to intervening more rapidly. But how many labs do we have [in India] that have that level of capacity?

So, tomorrow's world must learn from the lessons from the polio campaign. When safe drinking water or sanitation could not be provided, we managed with a vaccine. That was good, but then the vaccine itself was contributing to vaccine-derived paralysis, thus we are now planning to move to injectable vaccines. Again, that's possible because we have those technologies. When you evolve in your understanding of a disease, you evolve in your capacity to intervene, and your technology also has to evolve with it. From iron lungs in New York, we moved to ventilators, which were an invention in a Danish intensive care unit. Today, modern ventilators are so technologically advanced, [they] can do so many things.

We must learn from the past and use our technological resources to the optimum. For example, I went to an international meeting, organised by WHO, on rehabilitation of persons with disability. There was a technologist from Italy who was looking at artificial intelligence and software development, who presented a fascinating paper on technological innovations. I asked him how many such centres Italy has. He said, 'We already have six such centres'. A small country with a small population has such advanced technological centres. So tomorrow, if we were to follow the aatmanirbhar [self reliant] vision of our prime minister, we have to ensure that we develop the technological capacity in every region in India. Looking at our population, we can build that and we should.

You talked about vaccine-induced polio paralysis. Were you referring to the oral polio vaccines versus the injectable vaccines?

Injectable vaccine is a killed virus vaccine. It doesn't cause paralysis. It's the oral vaccine that [can] cause paralysis.

Is the oral polio vaccine being eased out?

Yes. If you look at the number of vaccine-derived paralysis [cases], they've also been going down. Earlier, we were having more frequent National Immunisation Days, where every child under five years was being immunised with an oral polio vaccine. These children will have the virus multiplying in their intestines, then they will excrete the virus and some of these [viruses] may develop mutations and have the capacity to cause paralysis. These are known as vaccine-derived paralytic conditions. The number of National Immunisation Days have been reduced now to three per annum so the numbers [of vaccine-derived paralysis cases] have reduced. I think the total number globally is a very small number. Still, whatever you see in a very few countries, you do have the numbers that are there. So we have to understand that surveillance for polio needs to be continued.

We will move on to the injectable [polio] vaccine as time proceeds, but there are catches to the injectable vaccine. Logistically, it's more challenging to give. The oral polio vaccine is easy to deliver. We don't need a nurse or a pressure injector. We don't need technology for that. It's just a simple drop being given. So we may lose out on access if you move to injectables. We have to understand the dynamics of all this, analyse it and take resourceful measures.

What's the one big lesson from polio that you've seen over the years, including for this whole period of Covid-19, our battle to make it endemic and eradicate it?

Polio evolved over decades. It gave us time. It killed few, but disabled many more. It created a permanent repository of disabled persons. Covid-19 did not give us time. I followed Covid-19 very closely. When you have such an overwhelming, war-like situation, you're in fighting mode. Even in that situation, you have to be a team. So all the doctors got busy with caring. They did not have time to reflect or research. They didn't have serious research that could come out with answers.

Epidemiological research is research on populations and what happens to them and human bench research is a different ballgame. But epidemiological research, in pandemics and epidemics, should be a frontline research programme for governments. There has to be huge prioritisation for that. In fact, we do not have such appointments. There should be dedicated research. The Indian Council of Medical Research alone with a limited number of staff cannot handle this. Every medical college should have. For example, in the department of orthopaedics at Harvard University, there'll be 30 faculty members, and about 10 of them would be just for research while the clinicians are [doing] clinical work. With Covid-19, everyone got busy with clinical work, doing mundane care work. But serious analytical research should be dedicated to people that can do research, as well as do clinical work. You need to have a combination of the two.

This is one worry that I have. I don't know how many follow the research news that came up last month, of genetic editing to cure a person with sickle cell disease. That's a huge advantage [for developed countries]. Genetic editing technology, the knowledge resource is there in developed countries. Tomorrow's world will be not drugs, pills and potions, it'll all be genetic. Hypertension will be cured by genetic editing, fracture healing by gene modification that stimulates bone formation, the future of diabetic treatment is gene modification to improve insulin production. Unless [India is] prepared to have research teams who can develop such things, we will again be paying [for] patents and will have to procure expensive genetic medicines from the West, and we'll continue to be poor.

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