Poliomyelitis in Developing Countries

POLIOMYELITIS IN DEVELOPING COUNTRIES

That surely-the weak shall perish and only the fit survive William Robert Service

The developing countries of the world include many countries in the tropics and subtropics, and over half the world's population. This probably amounts to over two thousand million people. Life is often precarious, and a single storm or a cholera epidemic, such as occurs in Pakistan or India, or a famine or war, can cause hundreds of thousands of deaths, and affect the permanent health of millions. Those already crippled in these circumstances will often be the first to die. Many, in addition, will die of intercurrent disease and malnutrition before maturity.

Economically poor countries in the tropics and subtropics include most of Asia and Africa, the Pacific Islands and Indonesia, and much of Central and South America. The terrain varies from jungle to desert, and from tropical coasts to ice and snow in the mountainous districts. The population varies from some of the most sparsely populated to some of the most densely inhabited areas of the world.

The conditions in which many people exist, although improving, are still often extremely primitive. Houses are usually made of mud, grass and reeds, and only the rich have a corrugated iron roof. Windows may be scanty or absent, and overcrowding is the rule rather than the exception. Sanitation is primitive, and water supplies are not only limited, but often heavily polluted with human excreta. Numerous intestinal diseases are endemic, and these include typhoid, bacillary dysentery and other gastrointestinal disorders. The enterovirus flora in the tropical and subtropical areas are often extensive as a result, and may considerably decrease the ability of oral polio vaccine to multiply in the gut and produce an immunity. Helminthic infections, schistosomiasis and chronic malaria are also almost universal. Malnutrition is often more common than undernutrition, and few so-called healthy patients are well. Average haemoglobin levels are often less than 8 grams per cent, even in apparently healthy patients. The infant mortality rate is appallingly high and the average expectation of life in those who survive infancy is still low, although improving.

Infants are likely to be infected at an early stage with many gastrointestinal infections, including endemic poliomyelitis. These will usually occur in the first few months of life, however, when the baby still has maternal antibodies from the placenta or breast milk. Subclinical infection with the poliovirus resulting in immunity without paralysis will therefore often occur. It is only when standards of health improve, and the child first becomes infected with the poliovirus at the age of two or three years, when maternal antibodies are negligible, that paralysis in appreciable numbers of patients may occur.

Epidemics are likely to become much more frequent unless overall immunisation schemes are put rapidly into effect. In many tropical and subtropical countries the cost of vaccine, the difficulty of distribution in many inaccessible parts of the world, and the high enterovirus content of intestinal flora in warmer climates, will considerably diminish the chance of success. The excellent and comprehensive Polio Plus immunisation scheme of Rotary International has made a considerable difference to the incidence of new cases of poliomyelitis in the tropics and subtropics. Many cases still occur due to the difficulty of keeping the vaccine refrigerated and enterovirus interference. In addition millions of patients with residual paralysis are still untreated in many developing countries of the world. The Untreated Polio Patient

The economic results of poliomyelitis can be devastating. Each epidemic will leave its residue of paralysed, patients, and unlike most other diseases, these patients will usually remain disabled. Lack of hospital facilities will mean that many will be condemned to crawling on the ground, and deformities and contractures will result. (Fig. 2(a)) The difficulties of getting these unfortunate children upright and walking in suitable supports, and with operations if necessary is more difficult the longer they remain untreated.

The number of severely paralysed patients with poliomyelitis in Uganda alone is about 30,000, but the total number with some degree of residual paralysis following polio in 1997 is reported to be over 250,000 in 1997, out of a total population of only 18 million people. Most other countries in Africa have very similar problems, and the number of untreated paralysed polio patients in Nigeria has been estimated at over 1,000,000. The total number of untreated polio in the developing countries of the world is probably several million. Little has been done for any of these patients, and most, through ignorance and poverty, will die before maturity. (Fig.2)

The majority of severely paralysed patients are often left uneducated and neglected and allowed to drag themselves through the mud and dust, their wasted bodies covered in sores and insect bites, and their apathetic expressions only one indication of their hopeless plight. Their physical condition, however, usually belies a normal though uneducated mentality. In view of this, most of these patients can be got walking with simple calipers and other supports, preceded by simple operations if necessary.

There is therefore a need for urgent treatment before they are allowed to die of neglect and intercurrent infection. This is more so in view of the fact that once upright and walking, most of these patients, due to their normal mentality, can be educated or rehabilitated at a small fraction of the cost of supporting an otherwise helpless, uneducated, crawling cripple. In the following pages the management of these paralysed patients will be described. It will describe the simple splinting of the paralysed limbs with cheap but effective locally made calipers, the correction of contractures mainly by subcutaneous operations, through to the final rehabilitation of the patient and his or her return to their own community.