6 jul. 2018

Poliomielitis after Poliomyelitis, Lights and Shadows of the Eradication. An Introduction.



ARTICLE in HYGIEA INTERNATIONALIS AN INTERDISCIPLINARY JOURNAL FOR THE HISTORY OF PUBLIC HEALTH ·
JUNE 2015
DOI: 10.3384/hygiea.1403-8668.15111

Juan Antonio Rodríguez-Sánchez
Universidad de Salamanca

Available from: Juan Antonio Rodríguez-Sánchez
Retrieved on: 26 January 2016

By Juan Antonio Rodríguez-Sánchez
Introduction  October of 2013 the European Centre for Disease Prevention and Control raised the alarm about the possibility of the reintroduction of the polio virus in the European Region: Syria, a country absent poliomyelitis cases since 1995presented new cases due to the deterioration of the health conditions during the internal armed conflicts.1 This situation brought about the reappearance of the wild poliovirus type 1 in Israel,2 which as qualified in the scientific literature as a “silent reintroduction”.3
The European Region (according to the classification of the WHO) had obtained the eradication certificate for poliomyelitis in 2002, which is why the reappearance of the virus on the shores of the Mediterranean has posed serious questions and reflection about the eradication plan4 and old fears have resurfaced in 1 European Centre for Disease Prevention and Control, “Suspected outbreak of
poliomyelitis in Syria: Risk of importation and spread of poliovirus in the EU”, Rapid Risk Assessment. 23 October 2013. Cited 2014 Jan 17. Available from: http://www.ecdc.europa.eu/
en/publications/Publications/RRA%20poliomyelitis%20Syria%2021%2010%202013.pdf.
2 European Centre for Disease Prevention and Control, “Expert consultation on scientific evidence linked to polio virus in Israel and Syria”, Meeting Report. 5 November 2013.
Cited 2014 Jan 17. Available from: http://www.ecdc.europa.eu/en/publications/Publications/
Expert%20consultation%20mtg%20report%20-%20polio%20Israel%20Syria%20-%20final.pdf.
3 E. Kaliner, J. Moran-Gilad, I. Grotto, E. Somekh, E. Kopel, M. Gdalevich, E.Shimron, Y. Amikam, A. Leenthal, B. Lev and R. Gamzu, “Silent reintroduction of wild-type
poliovirus to Israel, 2013 – Risk communication challenges in na argumentative atmosphere”,
Euro Surveillance, 19(7) (2014), 17. Cited 2014 Mar 5. Available from:
http://www.eurosurveillance.org/images/dynamic/EE/V19N07/art20703.pdf
4 D. Heymann and Q. Ahmed, “The polio eradication end game: what it means for Europe”, Euro Surveillance, 19(7) (2014), 17. Cited 2014 Mar 5. Available from:
http://www.eurosurveillance.org/images/dynamic/EE/V19N07/art20702.pdf
Occidental society towards an illness that, although it was far too easily forgotten,left a lasting impression on the central decades of the 20th century,5
Poliomyelitis is an infection which is produced by an enterovirus, of the picornaviridae family, denoted poliovirus and having 3 different serotypes (named 1, 2 and 3). Although 95% of infections proceed asymptomatically and create immunity in the individual, the remaining cases can produce an effect in the central nervous system, and even, a destruction of the motor neurons which leads to
paralysis, especially of the extremities and preferentially the lower ones. This form of Poliomyelitis called paralytic, and is seen in only 0.1% of cases of infection by poliovirus and its most serious form is when it affects the respiratory, intercostals and the diaphragm musculature and causing death if patient is not put on
mechanical ventilation6. It was precisely the paralytic form in children for which no immunity had been developed which gave the illness a particular significance in demolishing the dream of an invulnerable first world society, stigmatized several generations with sequelae which changed the way people with motor disabilities were viewed and how they saw themselves, something that permitted, finally, to go beyond the medical model of disability. The cultural imprint was accompanied by iconic elements such as the iron lung which joined the orthopedic devices with which they hoped to return their gait, as well as a definitive association between vaccination and childhood.

Despite the existence of references throughout the history of humanity,7 it didn’t evolve epidemically until the contemporary period and especially the 20th century,paradoxically in the countries with the most developed Health Services and lower child mortality – known as Payne’s Phenomenon – given that contact with the
poliovirus was belatedly produced when the child found itself unprotected by the immunity provided by breast feeding. Between 1921 and 1955 an expansion was 5 The two major references for the general history of polio are: John R. Paul, A History of
Poliomyelitis (New Haven, 1971); Mathew Smallman Raynor and Andrew D. Cliff, Poliomyelitis:
Emergence to Eradication (Oxford, 2006). The most relevant focus in the history of polio has been North America, and especially the United States, where it is necessary to highlight the monographs by Naomi Rogers, Dirt and Disease: Polio before FDR (New Brunswick, 1992) and David M. Oshinsky, Polio: An American Story (New York, 2005). Other works will be cited in the
next pages.

6 Jeffrey I. Cohen, “Enterovirus y reovirus”, in A. Fauci et al., eds, Harrison Principios de Medicina Interna (Madrid, 2012, 17 ed.), I:12081213. J.F. Modin, “Poliovirus”, in G.L.
Mandell, J.E. Bennett and R. Dolin, Enfermedades Infecciosas.Principios y Práctica, (Madrid, 2002,
5 ed.), pp. 23052315. V.R. Racaniello, “One hundred years of poliovirus pathogenesis”, Virology, 344 (2006), 916.
7 It is obligatory in any history of poliomyelitis to include the image of the Egyptian monument of Roma, priest of Astarte, which exhibits a characteristic poliomyelitis leg. Dating from the 18 dynasty, between 1403 and 1365 approximately around the reign of Amenophis III.witnessed, reaching its peak in the second half of the 50s and beginning of the 60s.This tendency was reverted thanks to the appearance of 2 types of vaccine.
The injectable vaccine by Jonas Salk (which contained an inactivated virus: IPV)provided the first effective intervention in the halting of the epidemic since the great campaign carried out in the United States in 1955.9 However, to achieve a collective immunity and interrupt the transmission of the wild poliovirus, an
attenuated vaccine was necessary – like that investigated by Hilary Koprowski10 which while containing a minimum risk of producing the illness (VAPP), it also had the clear advantage of being able to transmit the immunization passively to unvaccinated people if a high enough percentage of the population was reached. In this way, fundamentally through the investigations of Albert Sabin, results were seen, at the end of the 50s, diverse oral vaccination (OPV) campaigns which owing to its form of administration, were easier to apply, more economical, produced
intestinal immunity and allowed the multiplication and excretion of the vaccine virus with the effect of group immunization11.

Humans being the only reservoir for poliomyelitis meant that the appearance of this attenuated oral vaccine made the eradication of said virus possible. The global projects of the WHO had a singular aim in the Expanded Program on Immunization (EPI), started in 1974, with the objective of vaccination availability 8 §Mathew Smallman-Raynor and Andrew D. Cliff, Poliomyelitis: Emergence to Eradication (Oxford, 2006), pp. 187428.

9 Jonas Salk and his discovery have occupied a preferential place in scientific biographies, neighboring sometimes in the hagiography: the historic moment of the appearance of the vaccine,
its interpretation in key policy (compared to vaccines such as Sabin’s, linked to the sphere of socialist countries), the renounce of the rights of patent, the results obtained in the USA or , even
the empty space left in the pantheon of live scientist after the death of Alexander Fleming in 1955, are some of the elements to understand how his figure has eclipsed the other investigators.
10 Hilary Koprowski and Stanley Plotkin, “History of Koprowski Vaccine Against Poliomyelitis”, in Stanley A. Plotkin, ed., History of Vaccine Development (New York, 2011), pp.
155166. Hilary Koprowski and Stanley Plotkin, “Histoire alternative du vaccin oral”, in Anne-Marie Moulin, dir., L’aventure de la vaccination (Paris, 1996), pp. 299310.
11 In 1959, the First International Conference on Live Poliovirus Vaccine gave an account of 20 campaigns carried out in 15 countries. (Joseph L. Melnick, “The Picornaviruses”, in F.
Fenner and A. Gibbs, eds, Portraits of Viruses. A History of Virology. (Basel, 1988), pp. 147188.
Joseph Melnick and Stanley Plotkin, “Oral Polio Vaccine and the Results of Its Use”, in Stanley
A. Plotkin, ed., History of Vaccine Development (New York, 2011), pp. 167177). Those implemented in some Latin American countries were reported on by Sabin himself (Albert B.
Sabin, “Oral poliovirus vaccine: history of its development and use and current challenge to eliminate poliomyelitis from the world”, Journal of Infectious Diseases, 151(3) (1985), 420436. Lee
Hampton, “Albert Sabin and the Coalition to Eliminate Polio from the Americas”, American Journal of Public Health 99: 1 (2009), 3444). Vaccinations as ideological instruments during the
Cold War period and the role of Sabin´s vaccine are analysed by Dora Vargha, “Between East and West: Polio Vaccination across the Iron Curtain in Cold War Hungary”, Bulletin of the History of
Medicine, 88(2) (2014), 319343.

In every country. The success of Smallpox eradication encouraged the implementation of even more ambitious plans: in 1982, James P Grant motivated by UNICEF “The Child Survival Revolution”, supported by GOBI (an acronym of 4 interventions in child health, hose letter “I” corresponded to” immunization”)
and in 1988, the 41st World Health Assembly began the Global Polio EradicationInitiative (GPEI), a resolution with the aim of poliomyelitis eradication by the year  2000 and in answer to the private initiative set up three years earlier by Rotary International: The Polio plus Program. The magnitude of the project required the
participation of various state and private bodies. Successes12 and errors of provision13 aside, its presence continues with the goal of world health14.
Nevertheless, the particular characteristics of the poliomyelitis virus and the oral attenuated virus vaccine not only promoted the eradication but have also obligated us to reconsider some concepts: despite the elimination of the wild poliovirus in vast geographical areas, it is difficult to consider the eradication if vaccine-derived
poliovirus still circulate which are capable of producing new infections and, even epidemic outbreaks.15 The advent of the artificial synthesis of polio by Wimmer, Cello and Paul,16 who reconstructed it in vitro from sequential elements of
olignucleotides, incorporated a new element into the debate. Control, elimination, eradication and extinction take on nuances in which a world without the polio virus, a definite “endgame” appears difficult to envision.
Chronologies of Polio:

Beyond the Epidemiological Perception
In an attempt to understand the evolution of poliomyelitis on a global scale, a variety of authors have coincided in establishing, at least, five stages: one, prior to 12 Attaining the eradication certificates in the different regions of the WHO also points
to a chronology of success: 1994 (South American Region), 2000(Western Pacific Region), 2002 (European Region) and 2014(Southern Asian Region). The disappearance of wild poliovirus and currently of type 3, indicates significant advances.
13 The eradication programs were set up with fixed dates and deadlines to achieve saidobjectives, but have had to be systematically postponed.
14 World Health Organization, Polio Eradication & Endgame Strategic Plan 20132018
(Geneva, 2013). Cited 2014 Mar 23. Available from http://www.polioeradication.org/
Portals/0/Document/Resources/StrategyWork/PEESP_EN_US.pdf
15 Neal Nathanson and Olen M. Kew, “From Emergence to Eradication: The Epidemiology of Poliomyelitis Deconstructed”, American Journal of Epidemiology, 172 (2010),
12131229. Walter R. Dowdle, “The principles of disease elimination and eradication,” Bulletin of the World Health Organization, 76: Suppl. 2 (1998), 2225.
16 J. Cello, A.V. Paul, E. Wimmer, “Chemical Synthesis of Poliovirus cDNA: Generation
of Infectious Virus in the Absence of Natural Template”, Science, 297: 5583 (2002), 10161018.


The epidemics (until 1880), followed by another period of appearance of localized epidemic outbreaks (until 1920) and a subsequent stage of increase and global expansion that ran until 1955 at the moment that Jonas Salk´s vaccine permitted the dawning of a new era knows as retreat.17 For the Geographers Small man-
Raynor and Cliff, this would last until 1988, the year in which the aforementioned WHO program gave rise to a period with global eradication still inconclusive.
However, for the microbiologists/virologists Nathanson and Kew other phases are distinguished: 1973 would bring to a close an emblematic stage (the eradication of the wild poliovirus in the United States), followed by a lengthy period, until the
year 2000, of progress towards global eradication. A phase of challenges to the eradication arose in the years 2000 to 2010 and since the year 2000 a period characterized by problems derived from the oral vaccine has been established.18
It is an undeniable fact the usefulness of this chronology, structured by epidemiological data, which allows us to identify endemism, increase or remission and link them to specific interventions mediated by the public health policies.
However, as has been demonstrated, poliomyelitis is far more than an infection, due to its cultural impact (and economic) of its paralytogenics effects in the infant population. As such, other possible approaches exist because –as written by Jan
Sundin in the first issue of this magazine – the history of Public Health is an interdisciplinary field that goes beyond approximations exclusively demographicand epidemiological.19 The constructivist vision provokes us to consider elements which would allow the establishment of different chronologies as a function of the
social and cultural significance of polio in the West.

The great polio epidemics, especially those of the 40s to the 60s, mark the turning point in the social consideration of polio. Previously, before thes eepidemics, polio had been the source of attention for the scientific community, but –only since the epidemic outbreaks in the countries of North America and Europe did
poliomyelitis become part of the social imaginary as an illness associated with childhood and motor disability, the price of prosperity and progress (the “middle class plague”), the fear of the illness and the behavior patterns characteristics of epidemics as analyzed by Rosenberg.20
17 Mathew Smallman-Raynor and Andrew D. Cliff, Poliomyelitis: Emergence to Eradication (Oxford, 2006).
18 Neal Nathanson and Olen M. Kew, “From Emergence to Eradication: The Epidemiology
of Poliomyelitis Deconstructed”, American Journal of Epidemiology, 172 (2010), 12131229.
19 Jan Sundin, “Why Hygiea Internationalis?”, Hygiea Internationalis, 1(1) (1999), 57, p. 6.
20 Charles Rosenberg, Explaining Epidemics and Other Studies in the History of Medicine
(New York, 1992), pp. 293304.

The appearance of the vaccines of Salk and Sabin rapidly changed this
perception, and in spite of sporadic incidents (like the Cutter case),21 their
convincing results restored confidence in science stuffed with triumphalism. From
this moment onwards the struggle against polio is not only an objective of the
Public Health system assumed by the State, but by a united public, who made it
their responsibility to ensure the correct implementation of the vaccination
guidelines, bearing in mind the relationship between vaccination and infancy.
The initial optimism lead many countries to set elimination deadlines for polio,
internationally shared. This phase offered a major disparity between what the
scientific community and the national and international bodies considered with
respect to polio and what the public perceived, because polio at that time was only
visible through the consequences it produced and not through the surfacing of new
cases. Public Health policies were put to the test during this period, when the
illness began to associate itself with poverty stricken areas, economically
downtrodden or segregated for other reasons social groups, with restricted access to
sanitary services and lacking in health education. In the social imaginary the
significance of polio changed rapidly, and despite the marked persistent fear of the
same, the illness changed its sense, taking on characteristics which associated it with
“the others”.

This perception was emphasized when polio was considered to be an eradicable
disease and global programs were started for this end. The receipt of certificates of
eradication ratified the progressive introduction of the idea that polio is an “other
people” illness that belongs in far away regions of the world, a distant illness tied to
poverty and non-culture; polio as a developing countries illness. Those countries are
often referred to as needy recipients of international assistance (with scare
questioning of the ways of the same) and habitually are perceived as threatening a
reintroduction of the virus in the West. However, for society as a whole the onset
of a rapid forgetfulness of poliomyelitis has grave consequences such as the
appearance of anti-vaccinationist tendencies, the invisibility for people suffering the
consequences of polio and the difficulties in the recognition of post-poliomyelitis
syndrome and the denial of the rights of those afflicted by it.

The Problems of Polio
Poliomyelitis offers itself as an opportunity to examine the role of history in public
health.22 One of the most significant examples in history and its methods as tools
21 Paul A. Offit, The Cutter Incident. How America’s First Polio Vaccine Led to the
Growing Vaccine Crisis (New Haven, 2005).
22 Virginia Berridge, “History in Public Health: a New Development for History?”,
Hygiea Internationalis, 1(1) (1999), 2335. E. Perdiguero, J. Bernabeu, R. Huertas, E. Rodríguez-
for public health constitutes the previously quoted work of deconstruction of the
epidemiology of poliomyelitis carried out by Nathanson and Kew,23 in which the
analysis of long epidemiological series and of the abundant scientific literature
generated allowed them to identify the principal problems in the understanding of
the infection, its epidemics and the fight against them. Starting from a chronology
which clarifies the last ten years in different phases marked by the consequences of
the vaccinations, the authors proposed seven questions for the understanding of
polio for which they then searched for answers. Some of them allowed a connection
to be formed between the articles in the present dossier and problems present in the
struggle against polio.

One of the conditions which has determined the greater or lesser possibility of
eradication of the polio virus has been the seasonality. Tropical climates allow for
much longer periods when the transmission of the virus flourishes and in
competition with other enteroviruses, at the time that the attenuated oral vaccine
was at that moment more temperature sensitive than in the present. That presented
major difficulties in many countries for immunization of the population only
through the system of campaigns and a greater risk of the reintroduction of the
virus. The persistence of wild poliomyelitis would be determined by viral
epidemiology (the absence of seasonality in tropical countries, the coexistence with
diarrheal diseases, high density population and bad sanitary health services, which
facilitates transmission), the failure of the oral vaccine(for its own coexistence with
frequent diarrhea due to the enterovirus and for the lower efficiency of the trivalent
inoculation) and finally, for the material difficulty of vaccination, but also for
ideological resistance.

It still hasn’t been the object of an adequate historical analysis other than the
problems identified by Nathanson and Kew and that which only begins to supply
information in the present century. It deals with the epidemic outbreaks produced
by the vaccine-derived poliovirus. Although the events in Egypt are documented
since 1988, it will be the event on the island of Hispaniola (Haiti and the
Dominican Republic), in 2000 and 2001, which is the first to arouse interest, while
Ocaña, “History of health, a valuable tool in public health”, Journal of Epidemiology and
Community Health, 55 (2001), pp. 667673, p. 667.

23 Neal Nathanson and Olen M. Kew, “From Emergence to Eradication: The
Epidemiology of Poliomyelitis Deconstructed”, American Journal of Epidemiology 172 (2010),
12131229. Nathanson, from Global Health Program Office, School of Medicine, University of
Pennsylvania, had published, together with Martin, an article in 1979 in which they question
some epidemiological characteristics of poliomyelitis (Neal Nathanson and J.R. Martin, “The
epidemiology of poliomyelitis: enigmas surrounding its appearance, epidemicity, and
disappearance”, American Journal of Epidemiology, 110(6) (1979), 672692). Thirty years later,
they revisit those questions search for an explanation in history.

The most serious are produced in Nigeria from 2005.24 We must realize that the
cases of poliomyelitis which allowed the identification of these outbreaks were cases
of poliomyelitis that proceeded with paralytic forms and it is estimated that the
vaccine-associated paralytic poliomyelitis is one case in every 2.5 million
administered doses, though the risk does rise by some two thousand times in
situations of immunodeficiency.

We would find ourselves therefore, with new forms of the poliovirus circulating which have recovered their virulence and infective capacity. The fact that the oral vaccine itself provides immunity from these derived-polioviruses directs the offense strategy to increase vaccination in
order to achieved full coverage of the population.However, we now confront a
new problem: the eradication of polio will not be so if we substitute the wild
poliovirus for other vaccine-derived poliovirus. This leads the authors to consider
the final problem, which will be the post-eradication strategy and which would
have to go through a substitution of the oral vaccination for the dead virus
injectable vaccine, more expensive and more complex in its administration,
although all the research is currently directed towards obtaining a cheaper form,
combined with other viruses and an intradermal application.

On the contrary, its epidemiological perspective leaves out of its objectives the
analysis of one of the most serious problems currently in polio: its long term
repercussions. Beyond the crippling immediate consequences produced by the
virus, the awareness of the existence of post-polio syndrome confronts us with a
reality with important public health implications, especially in societies with scare
social sanitary coverage that jeopardizes the quality of life of affected people.

The History of Polio, History of the Present
From what we have seen above we can infer that the historical study of
poliomyelitis is a rich model in the history of illness steeped in complexity and with
a current interest for public health: we find ourselves before a recent pandemic, of
grand dimensions which has become the objective for the development of a major
global scale public health program to achieve its eradication, which is why historical
analysis is compulsory before proposing new interventions of such a magnitude in
24 Michael B.A. Oldstone, Viruses, Plagues, and History. Past, Present, and Future (New
York, 2010), pp. 159195, p. 160. Bernard Seytre and Mary Shaffer, The death of a disease: a
history of the eradication of poliomyelitis (New Brunswick, 2005), pp. 132147.
25 Jeffrey I. Cohen, “Enterovirus y reovirus”, in A. Fauci et al., eds, Harrison Principios de
Medicina Interna (Madrid, 2012, 17 ed.), I:12081213, p. 1209.
26 José Elías García-Sánchez, Enrique García-Sánchez, Enrique García-Merino and María
José Fresnadillo-Martínez, “La polio, el largo camino hacia el final de la partida”, Enfermedades
Infecciosas y Microbiología Clínica. In print. Cited 2015 Mar 17.
 Available from
http://dx.doi.org/10.106/j.eimc.2014.10.005

Other diseases. In an attempt to reach this goal problems have arisen and challenges
have been faced which make us pause for reflection on eradication, epidemiology
and public health.
Poliomyelitis doesn’t only grant us detailed historical demographic studies, but
also constitutes an excellent field to study the social construction of the illness and
the power relationships, the expert knowledge and the professionalism. The history
of medical technology has shown itself to be especially effective when applied to
poliomyelitis either in the role of vaccine, iron lung or orthopedic devices. As
generating disease of motor disability is a subsidiary of fruitful approaches from
disability studies, they are intimately linked to the history of the body and gender
studies.27 If we join to this the peculiarity that many of who suffered from the
infection are still alive, polio has invited a focused history from experience and
illness narratives.

On the whole, these implications of the history of poliomyelitis derives its
framework in the history of the present.29 Without getting involved in the debates
about the special historicity of the present, the definition of the temporal
significance of this historical perspective or the place of memory in history and the
role of witness (to quote only some controversial aspects), it is easy to understand
that the researcher who deals with poliomyelitis delves into experienced history,30 in
which the illness, its consequences and the sufferers are current. That persistence of
polio or those who live with the after-effects underline that concept of the history
of the present as an analysis of ongoing processes, inconclusive history or under
construction. Principally, those affected people, but including those who are
connected professionally or emotionally, who, conscious of being historical subjects
and having valuable memories, claim the right to question the significance of their
historical action.31 The acceptance of the experience and subjectivity are intimately
entwined with the transformation of the relationship between doctor and patient,
with the incorporation of the expert patient knowledge. Post-polio syndrome is
José Martínez-Pérez, “Presentación: la poliomyelitis como modelo para el studio de la
enfermedad en perspectiva histórica”, Asclepio, 61(1) (2009), 721.
 Roy Porter, “The Patient’s View: Doing Medical History from Below”, Theory and
Society, 14(2) (1985), 175198.
 Juan Antonio Rodríguez-Sánchez, La historia de la poliomielitis, historia del
presente”, Temperamentvm, 16 (2012). Cited 2013 Jan 30. Available from: http://www.indexf.
com/temperamentum/tn16/t2712.php
 “Historia vivida”, according to Aróstegui (Magdalena González, “La teorización de
Julio Aróstegui sobre la historia del tiempo presente como historia vivida”, Hispania Nova, 13
(2015), 126133.
 Josefina Cuesta Bustillo, “La historia del tiempo presente: estado de la cuestión”,
Studia Historica. Historia Contemporánea, 1 (1983), 227241.
32 Juan Antonio Rodríguez-Sánchez, “La persona enferma como experta: los cambios
sociosanitarios promovidos por el asociacionismo polio-postpolio en España”, Estudos do Século
XX, 12 (2012), 104122. M. Siegler, “La relación médico-paciente en la era de la medicina de

probably the most illuminating case, where the history of the present as a space of
confluence between past and future acquires it sense, between memory and
expectations33 and where the social demand for a commitment from the historian to
develop critical thinking is perceived with greater clarity.

The History of Poliomyelitis in Ibero-America
In the present dossier we approach the history of poliomyelitis in a vast, diverse
geographical space while having strong historical and cultural nexuses, made up of
the countries of the Iberian Peninsula and by those of the Atlantic coast in South
America. The presence of the illness (its incidence, significance and imaginaries), its
outbreaks and the fight against it (especially the prevention through vaccination
campaigns) are studied in Argentina, Uruguay and Brazil, Portugal and Spain,
between 1943 and the present. In those articles how the objective of control and
eradication of poliomyelitis is shaped and its relation to the global programs and
the consequences of these achievements in the general population and in affected
people in particular are analyzed.

On the Iberian Peninsula diverse research projects have been under development
since 2005, coordinated by Rosa Ballester, on the history of polio34 and into which
they have been integrating eight Spanish universities and two Portuguese ones.
There poliomyelitis has been approached from diverse perspectives and historical
angles in which the scientific, professional and social repercussions of the disease,
contextualized with the European and international framework have been
contemplated.35gestión”, in Limitación de prestaciones sanitarias (Madrid, 1997), pp. 4464. J. Jovell, “El pacientedel siglo XXI”, Anales del Sistema Sanitario de Navarra, 29: supl. 3 (2006), 8590.33 François Bedarida, “Definición, método y práctica de la Historia del Tiempo
Presente”, Cuadernos de Historia Contemporánea, 20 (1998), 1927. Julio Aróstegui, La historia
vivida. Sobre la historia del presente (Madrid, 2004), p. 102: the present would be the history
experienced by every subject and by their social collective, and it extends to their past perception
and the expectation about their own future.

 La poliomielitis en la España del siglo XX: repercusiones científicas, profesionales y sociales.
Funding Entity: MCYT. Proyectos I+D. Reference: HUM2005073788–C03. Duración: 2005
2008; Enfermedades emergentes y comunidades de pacientes. Funding Entity: MICIIN. Proyectos
nacionales de Promoción del Conocimiento. Plan Nacional de I+D+I.Duración. 20092012.
Reference: HAR200914068–C03. El reto de la erradicación de la poliomielitis y la amenaza del
síndrome post-polio: estrategias nacionales y acciones globales en la lucha contra la enfermedad y la
discapacidad (19632010). Funding Entity: MINECO. Duración: 20132015.
35 The results of these projects have been published in two dossiers in renamed
specialized magazines (José Martínez-Pérez, coord., “La poliomielitis y sus contextos: experiencias
colectivas e individuales ante la enfermedad en el siglo XX”, Asclepio, 61(1) (2009), 7192; Rosa
Ballester and María Isabel Porras, eds, “Políticas, respuestas sociales y movimientos asociativos

In contrast, the eradication of poliomyelitis in the Americas Region in 1994 has
attracted an disproportionate amount of attention from historians, with great
attention paid to northern countries and much less to the rest, without this level of
disinterest being justified by a lower rate of incidence. What is clear is the fact that
in the United States the epidemic outbreaks were early, intense and successive for
over than half a century which marked that society with a cultural imprint
reaffirmed by the figure of a president, Franklin Delano Roosevelt, affected by the
illness. But it is equally true that since the 30s, and fundamentally, in the 50s there
existed epidemics of special virulence in the Southern Cone. Thus the studies
carried out by Dilene Raimundo and the development team demonstrated, from
2002, the project “A história da poliomielite e de sua erradicação no Brasil”, whose
results were captured in diverse publications among them one which highlights a
group effort, the first of its kind, which collected research from diverse authors
about Brazil, Peru, Portugal, Spain and Pakistan.

Another group effort arose from a round table discussion held a year later during
the Congress of Spanish Society of the History of Medicine, coordinated by
Adriana Alvarez, Maria Isabel Porras and Maria Jose Baguena, entitled
“International perspectives of health in Latin America. Programs, methods and
local experiences in the struggle against poliomyelitis (19301960)”, during which
the cases from Costa Rica, Brazil, Mexico, Cuba and Argentina were analyzed.

Precisely it is Argentina, the country which, along with Cuba and the
aforementioned Brazil, has provoked the most interest in historians, especially
centered on the epidemic outbreaks and the publically developed policies to fight
against the infection, before and after the emergence of the vaccine, with the work
of Karina Ramacciotti, the already mentioned Alvarez and Daniela Testa, who
focus on the imaginaries and social response to the affected people with
poliomyelitis sequelae
Cuba´s case is of obvious interest, being the first country to frente a la poliomielitis: la experiencia europea”, Dynamis 32(2) (2012), 273414) and collective
books (María Isabel Porras Gallo, Mariano Ayarzagüena Sanz, Jaime de las Heras Salord y María
José Báguena Cervellera, coords., El drama de la polio: un problema social y familiar en la España
franquista (Madrid, 2013).
 Dilene Raimundo de Nascimento, org., A história da poliomielite (Rio de Janeiro, 2010).
 Adriana Álvarez, María Isabel Porras Gallo and María José Báguena, coords.,
“Perspectivas internacionales de la salud en la América Latina. Programas métodos y experiencias
locales en la lucha contra la poliomielitis (19301960)”, in María Isabel Porras et al., eds,
Transmisión del conocimiento médico e internacionalización de las prácticas sanitarias: una reflexión
histórica (Ciudad Real, 2011), pp. 233261.
Karina Inés Ramacciotti, “Las sombras de la política sanitaria durante el peronismo: los
brotes epidémicos en Buenos Aires”, Asclepio, 58(2) (2006), 115138. Adriana Álvarez, “’Parálisis y acción’: el caso argentino frente a los brotes de poliomielitis de mediados del siglo XX”, in María
Isabel Porras et al., eds, Transmisión del conocimiento médico e internacionalización de las prácticas
sanitarias: una reflexión histórica (Ciudad Real, 2011), pp. 259261. Daniela Testa, “Poliomielitis:
la ‘herencia maldita’ y la esperanza de la rehabilitación. La epidemia de 1956 en la ciudad de
apply mass campaigns of the oral vaccine in 1962 and in so doing eradicated polio
that same year. Once again epidemiology and vaccination are the focal point of
interest.

In spite of Chile,40 Peru,41 Costa Rica42 and Mexico43 also having something to
say in the history of polio, its battle and its eradication, the lack of attention which
a large part of the Americas region receives remains puzzling, despite pioneering the
eradication of the disease. The encyclopedic work of Kohn makes reference to not a
single epidemic outbreak in Ibero-America (for Spain or Portugal either),44 the
Cambridge World History of Human Disease hardly dedicates a paragraph to the
mention of vaccination programs in Argentina, Brazil, Chile, Costa Rica, Cuba,
Nicaragua and Paraguay45 and even the great and voluminous work of Smallman-
Raynor and Cliff muster only twelve pages of information about vaccination in
Latin America and the Caribbean, although it does include some references to
epidemic outbreaks on previous pages.46 Perhaps the only point of attention,

Buenos Aires”, Instersticios, 5(2) (2011), 309323; Daniela Testa, “La lucha contra la poliomielitis:
una alianza médico-social, Buenos Aires, 1943”, Salud Colectiva, 8(3) (2012), 299314; Daniela
Testa, “Curing by doing: la poliomielitis y el surgimiento de la terapia ocupacional en Argentina,
19561959”, História, Ciências, Saúde – Manguinhos, 20(4) (2013), 15711584; Daniela Testa, “El
síndrome pos-polio y sus anudamientos en el pasado”, Instersticios, 8(1) (2014), 233248.
39 However, the works of Más Lago and Enrique Beldarraín speak of subsequent cases of
unvaccinated children, the suspicion of interruption of wild poliovirus circulation in 1967 and its
confirmation from 1970. P. Más Lago, “Eradication of poliomyelitis in Cuba: a historical
perspective”, Bulletin of the World Health Organization, 77(8) (1999), 681687. Enrique
Beldarraín, “Poliomyelitis and Its Elimination In Cuba: An Historical Overview”, MEDICC
Review, 15(2) (2013), 3036. Cited 2014 Jan 23- Available from http://www.medicc.org/
mediccreview/index.php?issue=24&id=302&a=va
40 Enrique Laval, “Anotaciones para la historia de la poliomielitis en Chile”, Revista
Chilena de Infectología 24(3) (2007), 247250.
41 Deepak Sobti, Marcos Cueto and Y. He, “A public health achievement under
adversity: the eradication of poliomyelitis from Peru, 1991”, American Journal of Public Health,
2014, 104(12), 22982305.
42 Ana Paulina Malavassi Aguilar, “Representaciones sobre la epidemia de poliomielitis en
el periódico La Nación. Costa Rica, 1954”, in María Isabel Porras et al., eds, Transmisión del
conocimiento médico e internacionalización de las prácticas sanitarias: una reflexión histórica (Ciudad
Real, 2011), pp. 237239.
43 Ana María Carrillo, “Vacunación y educación higiénica en la campaña contra la
poliomielitis en México”, in María Isabel Porras et al., eds, Transmisión del conocimiento médico e
internacionalización de las prácticas sanitarias: una reflexión histórica (Ciudad Real, 2011), pp. 247251.
44 George C. Kohn, Encyclopedia of Plague and Pestilence: From Ancient Times to the
Present (New York, 1995).
45 Kenneth F. Kiple, ed., The Cambridge World History of Human Disease Past and Present
(Cambridge, 1993), p. 949. Kenneth F. Kiple, ed., The Cambridge Historical Dictionary of Disease
(Cambridge, 2003).
46 Mathew Smallman-Raynor and Andrew D. Cliff, Poliomyelitis: Emergence to
Eradication (Oxford, 2006), pp. 511523.

embedded in triumphalist rhetoric, has been the frequent inclusion of the
photographs of Peruvian child Luis Fermin Tenorio as the last affected soul in the
Americas Region. The necessity for new studies are therefore confirmed, and above
all, publications that halt the concealment of the sanitary situation in non-English
speaking countries.47

Polio: Towards a Comparative History of the Present Time

The history of the present was given incentive by the resurgence, from the 70s of
the last century, of a new political history in which reflection on power, beyond
that of the institutionalized, was bound with society and culture. The history of
poliomyelitis and, more concretely, of the international projects to combat it is an
appropriate theme for approximations in which the tensions produced between the
international sanitary organizations and their policies and the application of the
same on a national level are explored. This dialogue between local and international
levels is also produced in the universalization of scientific knowledge. In his study
of poliomyelitis in the Argentinian province of Cordoba, Adrián Carbonetti
analysis in this dossier the role of local social factors in the autochthonous
production of expert knowledge. The acceptance of foreign knowledge on
poliomyelitis (that is to say from North American and European science) is not
static, producing a fresh signification of this and the creation of their own research
strategies.

However, the most emphasized characteristic of the sanitary policies with regards
to poliomyelitis was the adoption of international commitments in the fight against
the same one that they led, in 1988, the ambitious global eradication (the Global
Polio Eradication Initiative), which Ballester, Porras and Baguena analyse in their
article on the Spanish case in its European context. Various talking points are
produced on international bodies which affect the strategies to combat
poliomyelitis: the WHO´s own composition meant that up to the 60s global
eradication projects were not established (smallpox being the first, successful and,
as such, encouraging), a composition that was also influential in the commitment
by the Primary Healthcare signed in Alma-Ata in 1978 and partially failed, with
inevitable consequences in the form of vaccination and the organization of
Three differents research networks are focused on History of diseases (which include
polio): Red de Estudios Histórico-Comparativos de la Medicina y la Salud Pública
Latinoamericanas, Red de Viejas y Nuevas Enfermedades de la Asociación Latino-Americana de Población y la Red Iberoamericana de Investigación en Historia de la Poliomielitis y el Síndrome
Post-Polio.

Epidemiological security One final point to consider is one which arises from the
WHO crisis in the 80s and drives a progressive increase in nongovernmental
funding, a very significant fact in the participation of different organizations in the
eradication of polio (National Governments in coordination with the four
spearheading partners -WHO, UNICEF, Rotary International and the Centers for
Disease Control and Prevention- to which others can be added, such as the World
Bank or the Bill & Melinda Gates Foundation) or in the Global Alliance for
Vaccines and Immunization (GAVI).49 In our case the role conducted by the Pan
American Health Association (PAHO) acquires a special interest, as much in the
heart of the WHO as in its work for the eradication of polio in the Americas
Region (even facing its criteria to those of the international bodies), the first to
achieve the certificate in 1994.50 This contextualization of the Spanish case with the
European and Global strategies allow a reflection on the necessity to go beyond of
the collective studies to carry out comparative studies which permit the analysis of
the role of local determining factors and the acceptance and application of global
strategies, their adaptation and results obtained. Although the national studies can
illustrate many of these aspects, it is the comparative perspective which detects
critical elements for the research. The well-known article by Lindner and Blume
about the development of vaccines (IPV and OPV) and the adoption of one kind
or another in the United Kingdom (England and Wales), the Netherlands and
West Germany, shows three different processes of introduction and use. Their
analysis of the intensity of the epidemic, organization of the health services and its
financing, the production (state or private) of the vaccine and the activities
(scientific and political) towards it, international relations, and above all, the
existence of prior national developments with respect to the illness and the
vaccination are some of the elements which authors claim enrich the comparative
studies.
Marcos Cueto, “Los orígenes de la Atención Primaria de Salud y la Atención Primaria
Selectiva de Salud”, in Marcos Cueto and Víctor Zamora, eds, Historia, Salud y Globalización
(Lima, 2006), pp. 2758.
 Theodore M. Brown, Marcos Cueto and Elizabeth Fee, “The World Health
Organization and the Transition From ‘International’ to ‘Global’ Public Health”, American
Journal of Public Health, 96(1) (2006), 6272.
 Miguel Armando Mosquera Gordillo, Natalia Barón Cano and Rosa Ballester Añón,
“El camino hacia la erradicación de la poliomielitis a través de la Organización Panamericana de
la Salud”, Revista Panamericana de Salud Pública, 36(3) (2014), 185192. Lee Hampton, “Albert
Sabin and the Coalition to Eliminate Polio from the Americas”, American Journal of Public
Health, 99(1) (2009), 3444. Marcos Cueto, El valor de la salud. Una historia de la OPS
(Washington, 2004).
51 Ulrike Lindner and Stuart S. Blume, “Vaccine Innovation and Adoption: Polio
Vaccines in the UK, the Netherlands and West Germany, 19551965”, Medical History, 50
(2006), 425446.

For the comparative polio study in Ibero-America, despite the study being
pioneered for Brazil and Peru, aforementioned,52 and others for the Iberian
Peninsula,53 a specific proposal still doesn’t exist, although there exists a framework
with a solid scientific foundation and meticulously organized by an ample
international team, coordinated by Emilio Quevedo, for the comparative study of
public health, health professions and their relationship with society,54 Adriana
Alvarez was appointed to this project, and in his article about poliomyelitis in
Argentina and Uruguay, highlights the complexity of comparative studies between
countries which show marked differences themselves internally according to
geographical areas. Through the analysis of health policies, vaccination programs
and epidemiological data, we can compare the evolution of the illness in both
countries during the governments of Peron and Batlle and their great epidemic
strategies to combat the outbreaks of the mid 50s.

Furthermore, from the comparative perspective the representation of
poliomyelitis and post-polio syndrome are tackled in the Spanish-Portuguese press
by Guerra and Rodriguez –Sanchez. If contemporary history has always counted on
the press as a relevant source, then the history of the present finds facts about the
influence in its public and political agendas, with the effect of a configuration of
identities. Post-polio Syndrome, dealt with by the comparative study, exemplifies
the vicious circles established: the absence of collectives and social movements for
polio-affected people leads to their invisibility in the Portuguese press and this
disappearance causes a spread of misinformation across public society (and worse
still, of the people affected) about the existence of the syndrome. To this must be
52 Dilene Raimundo do Nascimento, Marcos Cueto, Eduardo Ponce Maranhão and Deepak
Sobti, “A erradicação da poliomielite na América Latina: comparando Brasil e Peru”, in Dilene
Raimundo de Nascimento, org., A história da poliomielite (Rio de Janeiro, 2010), pp. 161176.
53 Sandrine Martins Pinto, Inês Guerra, Juan Antonio Rodríguez-Sánchez, João Rui Pita
y Ana Leonor Pereira, “De las campañas de vacunación al calendario vacunal: el Programa
Nacional de Vacinação portugués y las Campañas Nacionales de Vacunación Antipoliomielítica
en España (19631976)”, in Ricardo Campos Marín, Ángel González de Pablo, María Isabel
Porras Gallo y Luis Montiel, eds, Medicina y poder político (Madrid, 2014), pp. 203209. Juan
Antonio Rodríguez-Sánchez, Rosa Ballester Añón and Inês Guerra Santos, “El movimento
associativo: uma perspectiva internacional, nacional y de los casos de Madrid, Valencia y Castilla
– La Mancha”, in María Isabel Porras Gallo, Mariano Ayarzagüena Sanz, Jaime de las Heras
Salord y María José Báguena Cervellera, coords., El drama de la polio: un problema social y familiar
en la España franquista (Madrid, 2013), pp. 233257. João Rui Pita and Juan Antonio Rodríguez-
Sánchez, “Actitudes ante la polio en España y Portugal: estudio comparativo”, in Teresa Ortiz et
al., eds, La experiencia de enfermar en perspectiva histórica (Granada, 2008), pp. 331334.
54 Emilio Quevedo, Mario Hernández, Claudia Cortés and Juan Carlos Eslava, “Un
modelo para armar: Una propuesta metodológica para abordar el estudio comparativo de la
historia de la salud pública, de las profesiones de la salud y de sus relaciones de doble vía con la
sociedad”, Revista de Ciencias de la Salud, 11(3) (2013), 295321.
added its effect in relation to social movements and in relation to the creation and
reconstruction of identities.

Memory, Testimony and History of Polio
in Light of Post-Polio Syndrome
In fact, a characteristic of the history of the present is the coexistence of territories
which are troublesome to demarcate: history, investigative journalism and memory
narratives 55. Poliomyelitis has not only been common to its focus, but it has
illustrated them prolifically. The vaccines, their trials and the incidents during their
application has given rise to controversies that have elicited approaches from
investigative journalism which have exalted the figure of Jonas Salk56 or has related
Koprowski´s trials with the origin of HIV,57 linked diverse cancers with the
contamination of the vaccines by the SV40,58 or even in the poliomyelitis outbreaks
from the vaccine-derived polioviruses.59 In such cases, history and journalism can,
when the approximations are rigorous, be very close to the mark: share multiple
sources, respond to social demand, and contrast documents and testimonies in
search of their veracity.
However, an extant illness, whose survivors have been scarred by paralytic effects,
invite us to convert their memory into one of the pillars of history. The
autobiographical narratives have frequently interlaced in an effort to recover a
collective memory like in the cases of Black61 and Shell,62 which acquired major
historical aspiration in that of Sass63 and Wilson64 coming from the fulfillment and
 Montserrat Huguet Santos, “Historia del Tiempo Presente e Historia de las Relaciones
Internacionales”, AYER, 42 (2001), 4369.
56 Jeffrey Kluger, Splendid Solution. Jonas Salk and the Conquest of Polio (New York, 2004)
57 Edward Hooper, The River: A Journey to the Source of HIV and AIDS (Boston, 1999).
58 Debbie Bookchin and Jim Schumacher, The Virus and the Vaccine. Contaminated
Vaccine, Deadly Cancers, and Government Neglect (New York, 2004). A review in the scientific
literature: Michele Carbone, Paola Rizzo and Harvey I. Pass, “Simian virus 40, poliovaccines and
human tumors: a review of recent developments”, Oncogene, 15 (1997), 18771888.
59 Bernard Seytre and Mary Shaffer, The death of a disease: a history of the eradication of
poliomyelitis (New Brunswick, 2005).
60 Montserrat Huguet Santos, “Historia del Tiempo Presente e Historia de las Relaciones
Internacionales”, AYER, 42 (2001), 4369.
61 Kathryn Black, In the Shadow of Polio. A Personal and Social History (Cambridge,
Mass., 1996).
62 Marc Shell, Polio and its Aftermath. The Paralysis of Culture (Cambridge, Mass., 2005).
Cfr. Rosa Ballester, “Entre la metáfora y la realidad. Discapacidad e identidad en la historia de la
poliomielitis”, Dynamis, 28 (2008), 419425.
63 Edmund J. Sass, Polio’s Legacy. An Oral History (Lanham, Maryland, 1996).
64 Daniel J. Wilson, Living with Polio. The Epidemic and its Survivors (Chicago, 2005).

Analysis of interviews of affected people65. Memory archives as a baseline for an oral
history of poliomyelitis have been frequent in United States66 and Canadian67
historiography, making the experience – including the emotions – one of the most
enriching aspects in the history of the illness. Adding to this as much the
contributions framed as historical research or as journalistic research have been
developed on many occasions by people affected by polio, incorporating new
nuances on motivation and subjectivity, memory and history, commitment and
activism.
Abundant motives hamper our field of research, the Ibero-American space, we
count on autobiographical publications, and moreover there are developing
projects, many of whose objectives are articulated in an oral history setting. Dilene
Raimundo has led some of these projects69 which have generated an archive of
testimonials available online.70 Her article in this dossier concerning the eradication
of poliomyelitis in Brazil tells of one of these testimonies to focus on one of the
aspects which usually serve as a corollary in the majority part of the historical
accounts on poliomyelitis: post-polio syndrome. The threat of the syndrome
gravitates in almost every work centered on the testimonies, establishing the worry
for those, who having fought for the consideration of the disability as functional
diversity, become ill once more.71
The testimonies of scientists are usually written memoirs published in collective works:
Anne-Marie Moulin, dir., L’aventure de la vaccination (Paris, 1996). Thomas M. Daniel and
Frederick C. Robbins, eds, Polio (Rochester, 1997). Stanley A. Plotkin, ed., History of Vaccine
Development (New York, 2011).
66 Tony Gould, A Summer Plague. Polio and its Survivors (New Haven, 1995). Julie Silver
and Daniel J. Wilson, Polio Voices. An Oral History from the American Polio Epidemics and
Worldwide Eradication Efforts (Westport, Connect, 2007).
67 Sally Aitken, Helen D’Orazio and Stewart Valin, eds, Walking Fingers. The Story of
Polio and Those Who Lived with It (Georgetown, Ontario, 2004).
68 Serve as examples Aitken, Wilson, Smith, Gould, Shell or Sass.
69 A história da poliomielite e de sua erradicação no Brasil (Programa Estratégico de
Pesquisa da Casa de Oswaldo Cruz, Conselho Nacional de Pesquisa de Brasil). A erradicação da
poliomielite. Uma história comparada: Brasil e Peru (Edital Universal 01/2002-CNPq).
70 Anna Beatriz de Sá Almeida, Laurinda Rosa Maciel and Dilene Raimundo do
Nascimento, Memórias da Poliomielite: acervo de depoimentos orais. 2005. Available from:
http://www.bvspolio.coc.fiocruz.br/polio/brasil/acervo/memoriaPoliomielite/index.htm.
71 Heather Green Wooten, The Polio Years in Texas. Battling a Terrifying Unknown
(Texas, 2009). Sally Aitken, Helen D’Orazio and Stewart Valin, eds, Walking Fingers. The Story of
Polio and Those Who Lived with It (Georgetown, Ontario, 2004). Julie Silver and Daniel J.
Wilson, Polio Voices. An Oral History from the American Polio Epidemics and Worldwide
Eradication Efforts (Westport, Connect., 2007). Daniel J. Wilson, Living with Polio. The Epidemic
and its Survivors (Chicago, 2005), pp. 228251. Edmund J. Sass, Polio’s Legacy. An Oral History
(Lanham, Maryland, 1996). Marc Shell, Polio and its Aftermath. The Paralysis of Culture
(Cambridge, Mass., 2005), pp. 206210. Tony Gould, A Summer Plague. Polio and its Survivors
(New Haven, 1995).
If the problems in achieving an authentic eradication of poliomyelitis make it
necessary to revisit the past, post-polio syndrome presents one of the major current
challenges that should be approached from the point of view of the stories of the
people who have lived through the illness and its aftermath, as well as the social
significance which the disease has had. Post-polio syndrome exceeds the mere
medical and scientific pursuit in that it influences some key elements of the cultural
construction of polio in western society: if the person with poliomyelitis sequelae
has symbolized the triumph of effort, of will, of the mind over body (and so they
have individually assumed this continuous challenge to demonstrate their capacity),
the appearance of the syndrome is borne as a failure, a setback and a loss of
meaning for the vital project. However, in contrast to that society which is bending
over backwards to find a solution to the threat which children suffered and to assist
in their rehabilitation, the person with post-polio syndrome confronts obscurity
and abandonment in many parts of the world. The necessity to complete this
process of eradication, the much announced “endgame”, diverts attention from the
consequences of polio that linger on, affecting the world free of polio.72 Exclusively
in this context is it possible to conceive of a syndrome that (in spite of being
extensively studied by Dalakas and Halstead and internationally debated since the
80s)73 wasn’t included in the International Classification of Diseases until the year
2010,74 and to all intents and purposes, faced with the problems of low prevalence
diseases.75 Similarly, it is the people affected who lead social movements in which
the role of the expert patient is revalidated, with the help of new virtual social
networks, search for and organize the information that many health professionals
worldwide are ignorant of.
Poliomyelitis, despite the continually strengthening perception of it as an illness
of the past, continues to cause problems for the present public health system and
challenges for the immediate future. The answers, more than in any other case, pass
necessarily through interdisciplinary areas in which history provides vital keys and
can still illuminate multiple aspects open for investigation.
72 Nora Ellen Groce, Lena Morgan Banks and Michael Ashley Stein, “Surviving polio in
a post-polio world”, Social Science & Medicine 107 (2014), pp. 171178.
73 Tony Gould, A Summer Plague. Polio and its Survivors (New Haven, 1995), pp. 209217.
74 International Statistical Classification of Diseases and Related Health Problems 10th
Revision (ICD-10 Version:2010). Available from: http://apps.who.int/classifications/icd10/
browse/2010/en Chapter VI. Diseases of the nervous system (G00–G99). Systemic atrophies
primarily affecting the central nervous system (G10–G14). G14 Postpolio Syndrome
http://apps.who.int/classifications/icd10/browse/2010/en#/G10-G14 Polio sequelae are codified
as B91.
75 Marc Shell, Polio and its Aftermath. The Paralysis of Culture (Cambridge, Mass., 2005).
24
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Acknowledgements
This work has been carried out as part of Project HAR2012-39655-C04-03 of the
Spanish Ministry of Innovation, Economy and Competitiveness (MINECO) and
SA359A12-1 and SA251U14 (Junta de Castilla y León).


31
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