First in the Queue

I

On 26 April 1954, in the gymnasium of a school in McLean, Virginia, a six-year-old boy with a crew cut stood first in a queue and was given an injection in the arm.

His name was Randy Kerr. The village paediatrician, Richard Mulvaney, rolled up his sleeve and gave him the dose in front of the photographers [there was national press in a school gymnasium]. The boy said afterwards that it had hurt less than a penicillin injection.

With that jab began the largest clinical trial in history: one million eight hundred thousand children in forty-four states, half with vaccine and half with placebo or with observation, organised by a foundation funded with ten-cent coins sent by post [the March of Dimes].

None of those children —not Randy Kerr first of all— knew whether they were being given the vaccine or coloured water.

They were called “polio pioneers” and given a card with their name on it.

II

It has to be said why a trial of that size was needed, because it was not for statistical rigour.

Polio is a rare disease in terms of percentage. Most infections give no symptoms or give a slight temperature. Paralysis appears in fewer than one in every hundred infected. To demonstrate that a vaccine prevents something that happens to one in several thousand children a year, a very great many children are needed.

A placebo was needed, which is the uncomfortable part. Half of those kids received an injection of nothing, in the middle of an epidemic, with the parents signing a paper saying they accepted.

In 1952 there were fifty-seven thousand cases in a single country and more than three thousand dead [the worst year on record]. The swimming pools closed in summer, the cinemas emptied and there were photographs of whole halls with children inside iron lungs, metal cylinders that breathed for them.

The parents signed.

You have to picture the scene to understand it: a table in a gymnasium, a queue of kids with their sleeves rolled up, and parents who knew that half of it was water and took the child all the same. They did not do it out of trust in science; they did it because in August the swimming pools closed.

III

I was vaccinated with the other one, the drops on a sugar lump, and I do not remember it.

What I do have is the card. A blue card booklet with the health centre's ink stamps, my name written by hand and the dates of 1986 and 1987 in ink that has already turned brown. In the polio box there are three entries and a different signature in two of them.

I took it out of the drawer while writing this [it is still valid as a document] and discovered that in the last one there is a blot and a correction over the top, made with a different pen.

I have never seen an iron lung outside a photograph. I know nobody with after-effects. In my generation, in this country, polio is a word that appears on cards and not in conversations.

That is, once again, the same as with smallpox: the result of something working is that there ceases to be anything to tell.

Booster dose of the combined vaccine for a trip, today, at a private clinic: some thirty euros.

IV

Inside there are two ways of doing this, and both exist, and the difference between them is the best lesson in the history of vaccines.

Salk's, the one Randy Kerr received, carries dead viruses. The virus is cultured, killed with formalin and the corpse is injected. The immune system finds it in the blood, takes its measurements and makes antibodies that circulate; if one day the live virus arrives and enters the blood on its way to the nervous system, they intercept it there.

It protects the vaccinated person almost a hundred per cent against paralysis, and it does not stop the virus living in their gut.

Sabin's, the drops, carries live weakened virus. It is swallowed, settles in the gut as the real one would and provokes a response in the mucosa as well, so that the vaccinated person ceases to be a place where the virus can multiply. Besides, they excrete it, and pass the weakened version on to whoever lives with them.

That is: one protects whoever receives it and the other protects the neighbour too.

That detail, which looks technical, is what made it possible to eliminate the disease from whole continents. It has its price, because a live weakened virus can, very rarely, revert and become dangerous again, a few cases per million doses.

That option was chosen for decades in full knowledge [and is still chosen, according to the country and the stage of elimination]. A few cases caused by the vaccine in exchange for cutting the transmission of a disease that paralysed thousands.

The calculation is written in public reports and is not hidden anywhere. It is one of the few times a health decision of that kind is documented with that frankness.

V

What the 1954 trial inaugurated was not the vaccine. It was the scale.

One million eight hundred thousand subjects, hundreds of thousands of civilian volunteers, a registration system on card index sheets [one million eight hundred thousand cards] and a result announced in April 1955 at a press conference broadcast live on radio. Bells rang in some cities.

That way of doing things is what we take for normal today; evidence as a public event, with an announcement date, with anticipation and with headlines.

And with its reverse, which also had its debut then. When evidence is announced at a press conference, the error also comes out at a press conference, and both things travel at the same speed and by the same channels.

It also inaugurated the other side. Two weeks after that announcement, a manufacturer in California distributed batches with badly inactivated virus. Some forty thousand children had mild polio, two hundred were left with paralysis and ten died. It was called the “Cutter incident” and out of it came the federal batch control system.

The same campaign, in the same month, produced the greatest victory and the greatest disaster in the history of vaccines.

VI

The objection is the placebo and it has no clean way out.

With today's knowledge, giving saline to nine hundred thousand children in the middle of an epidemic would be unacceptable, and yet it was what made it possible to know that the vaccine worked and to what extent. Had everybody been vaccinated, the result would have been interpretable in ten ways and would probably have taken years longer.

There is no way of having both. Somebody has to be in the group that receives nothing, and that person, that year, was six years old and was in a queue in a gymnasium.

Against me, the usual in this series. I am the one who benefits from that decision without having been in either queue.

VII

Randy Kerr turned out to be in the group that received the placebo. They told him afterwards.

He was given the real vaccine when it was authorised, like everybody, and lived a normal life. He has told the story in newspapers every ten years, when somebody remembers the anniversary, and he always repeats the same sentence about the penicillin.

Of the other one million eight hundred thousand almost nothing is known. There are boxes with card index sheets in an archive, with names, schools and dates, and a batch number when it was their turn for the real vaccine. It is, probably, the largest file of named bodies that exists in this work, and nobody has read it whole.

That archive has a property that distinguishes it from all the others appearing here. It was not kept by a company or a ministry; it was built by a foundation with small donations, and the cards were filled in by schoolmistresses and volunteer mothers in school gymnasiums, by hand, with the child in front of them.

26 April 1954, first injection of the trial.

One million eight hundred thousand children; half of them, placebo.

12 April 1955, the announcement that it worked.

Weeks later, the incident of the batches: ten dead.

Booster today, at a private clinic: some thirty euros.

Blue card booklet, stamps from 1986 and 1987, and a blot corrected with a different pen.