Why We Still Have Polio

My White Paper:
Why We Still Have Polio

Professor’s Foreword

Whenever possible, I will provide models of the type of work this course is designed to produce. Today, I offer a draft of my own White Paper on the hypothesis that despite tremendous investment and goodwill from hopeful eradicators, we may never be free of polio.

Work in Progress

Like all research documents, the White Paper is a work in progress. It’s not intended to be a polished work product. I will continue to work on it during the semester, with the help of your feedback, and add to it (or delete sections that turn out to be irrelevant) as I modify my hypothesis in search of a thesis I can prove.

We write to find out what we believe.

The truth is, we don’t have a thought in our heads. We receive impressions, we experience sensations, our instincts control the momentary notions that flit across our consciousness: none of that adds up to actual ideas.

I believe you know what’s in my head. It’s ___________________ or __________________, or _______________ eating _________________.

When we write, or speak, we are forced to organize the chaos in our heads to communicate the patterns of our impressions in a comprehensible fashion. In other words, we don’t have ideas until we express them.

The process contains an imaginary step.

There is no value in “thinking about my sources.” Because thinking only occurs during writing, it’s useless to separate the composition process into stages that don’t involve writing, such as:

  1. Collect sources
  2. Read sources
  3. Think about sources
  4. Write about sources as I read them
  5. Organize our thoughts into patterns
  6. Write organized essay
  7. Endlessly revise

Thinking doesn’t occur during the reading process. We only react, mostly arguing with the text. We begin thinking when we begin writing. Step 3 by itself is a waste of time. Step 4, because it involves writing, is incredibly valuable. It puts the sources to use before we’re even certain what our thesis will be. Step 5 by itself is imaginary. The time to write about sources is while we’re reading them; the time to organize our thoughts is after we’ve written our first draft. 

Writing is Thinking

The most effective technique, instead, and the one we’ll use in this class, is to write as a way of having ideas and clarifying our arguments.

  1. Collect a Source
  2. Write about that Source
  3. Collect New Sources Suggested by a Developing Hypothesis
  4. Write about those Sources
  5. Repeat Beyond what is Needed
  6. Write a first draft that is way too long.
  7. Edit and organize into Persuasive Essay

Cutting, not writing, is the last step.

When we finish organizing, we’ll have too much material for a narrow thesis. The last step will be to eliminate non-essential material and edit our language for brevity and clarity, to prove one thing well instead of waving vaguely at everything.

For practice, we can try several ways to open.

A good way to decide how the process is going is to experiment with radically different openings. As we try on several, one or more will suggest themselves as the most likely thesis, or the one we can most effectively argue and support. Look for Practice Openings throughout this White Paper, in red.

This Week

Today, I’ll talk you through my sample White Paper to demonstrate the range of material that a straightforward thesis can accommodate. Then Friday, I’ll ask you to produce some sample opening paragraphs in class.


Why We Will Always Have Polio

A Practice Opening

Children are the saddest casualties, and too often the most vulnerable. As recently as 2014, in the latest catastrophe to spin out of the death fest in Syria, the local polio outbreak spread to Iraq. Despite what the New York Times called “an ambitious Middle East inoculation effort,” the conditions of war, including tens of thousands of internal refugees huddled in unclean camps, once again catapulted the insidious virus across international borders to threaten mostly the vulnerable children, this time in Iraq.
[Doesn’t actually have a thesis.]
[Need numbers on childhood infections to support this claim.]
[Note for further research: are children actually physically more vulnerable to the virus than adults? Or does their behavior, not their biology, make them easier to infect?]

A Practice Opening

The virus that causes polio thrives during conflict and mayhem. Repeatedly over the last half century, whenever mankind has come close to banishing the disease forever, human misadventures have invited it back. Certainly in times of war, but even during peace, we have failed to accomplish the ultimate eradication we seek. Nations [sects? religious factions?] are less cooperative now than in 1977, when we eradicated smallpox once and forever, and banished that dreaded disease from our planet.
[Still just a suggestion. Doesn’t actually claim that we’ll never eradicate polio.]

230px-Child_with_Smallpox_Bangladesh

Smallpox victim, Bangladesh

A Practice Opening

This generation is not ready to eradicate polio. An editorial in the journal Lancet, September 2006, relates the sad history of polio vaccination campaigns thwarted by distrust in the very communities they are meant to protect. Fear in poor countries that mass vaccination is a conspiracy by the developing world has for years complicated the efforts of volunteers to conduct the one-day mass immunization efforts that have been the most effective part of the World Health Organization’s program. Even when funding, volunteers, and sufficient doses have been present, the trust of the poor and often suspicious residents of vulnerable countries has been absent.

But the developing world has no monopoly on ignorance, willfulness, and distrust.
[In March, 2015, Time magazine, using data provided by the New York Times, reports that “measles has made a comeback, at least in New York City, where as many as 19 cases have been confirmed.”]
Update with more current source for 2015 Disneyland outbreak.

The small number of cases, for measles or for polio, is never a reason for complacency. For decades, childhood measles cases in the US, a triumphant result of universal vaccination, numbered zero. Said Time in 2014: “The emergence of these diseases—especially measles—is alarming, and mostly due to parents in the U.S. not vaccinating their kids.”

Purposeful Summary:
2014 Syrian Outbreak

[Sections like these, which might look like data dumps, are always purposeful summaries. The process of making our readings our own begins here, with the paraphrasing and shaping of source material into language that owes much to the original, but which can safely be called our own.]

The transmission of polio, a highly contagious disease that primarily afflicts children younger than 5 and can lead to partial and sometimes fatal paralysis, reflects one of the most insidious effects of the three-year-old Syria conflict, which has sent millions of refugees across the country’s borders and severely undermined its public health system.

For Iraq, the outbreak is the first time in 14 years that polio has appeared; the disease was absent even during the 2003-2011 war that began with the American-led invasion to topple Saddam Hussein.

World Health Organization officials said the first Iraqi polio case, that of a 6-month-old boy in Baghdad, was confirmed on March 30 by Iraq’s Ministry of Health and had the same genetic fingerprint as the virus that paralyzed 27 children in eastern Syria in October — both having originated in Pakistan, one of the few countries in the world where polio has not been eradicated. The Polio Global Eradication Initiative, a partnership that includes the W.H.O., reported two new Syria cases last week — in Aleppo and Hama, far from the original outbreak area.

Christopher Maher, the eastern Mediterranean manager of the W.H.O.’s Polio Eradication and Emergency Support unit, said that Iraqi officials had been immunizing children protectively since the Syria outbreak began, and that in light of the first confirmed case in their home country they were now expediting another scheduled round of vaccinations.

“At the moment, they’re madly preparing their response plan,” Mr. Maher said in a telephone interview. It takes multiple rounds of vaccine, taken orally, to immunize a child.

Iraq has an estimated five million children under the age of 5. While estimates vary on the number of infections for every confirmed case, and not all children develop symptoms, Mr. Maher said, “in all likelihood it would be dozens — you’ve got to assume there’s some extension of the transmission.”

The W.H.O. and UNICEF said in a joint statement on Sunday that Iraq’s expedited polio response was part of a broader vaccination effort in the region, with the goal of reaching more than 20 million children this week. Lebanon and Turkey will participate later this month, and Jordan and the Palestinian territories will be part of future vaccination rounds, said Juliette S. Touma, a spokeswoman for UNICEF’s regional office in Amman, Jordan.

“The recent detection of a polio case in Iraq after a 14-year absence is a reminder of the risk currently facing children throughout the region,” Maria Calivis, the UNICEF regional director for the Middle East and North Africa, said in the statement. “It is now even more imperative to boost routine immunizations to reach every child multiple times and do whatever we can to vaccinate children we could not reach in previous rounds.”

The statement acknowledged that the effort had “yet to reach especially vulnerable groups such as children who are on the move fleeing violence from Syria or those living in the midst of active conflict.”

Purposeful Summary:
Tragic Evidence of Insurmountable Opposition

Some rights advocates and public health experts have criticized the W.H.O. and other United Nations agencies for adopting an accommodating policy toward President Bashar al-Assad of Syria, who they contend has deliberately withheld inoculations against polio and other contagious diseases to insurgent-controlled areas.

Dr. Annie Sparrow, a pediatrician and deputy director of human rights at the Icahn School of Medicine at Mount Sinai in New York, said in a study published in February that the polio outbreak in Syria was far more widespread than just the cases reported by the W.H.O. The health organization has disputed her findings.

Dr. Sparrow said in a telephone interview on Monday that the most recent polio news from Iraq and Syria was both expected and alarming. “It should signal an absolute failure of the global eradication effort,” she said.

Mr. Assad’s forces, she said, “have been bombing the heck out of the people of Aleppo instead of vaccinating them, which is what they should be doing.”

While Mr. Maher said the spread to Iraq was not in itself surprising, health officials were uncertain about its precise path to Baghdad, where the victim had no obvious contact with possible carriers from Syria, most of them refugees concentrated near Iraq’s border with Syria.

“It’s great if you have clear-cut chain of transmission so you can easily see how this would happen — maybe a refugee child,” he said. “But where you would expect to see the virus would have been in the northwest, and not down in Baghdad.”

At the same time, he said, the confirmed case reflected the ability of the polio virus to find vulnerable victims, touching a child who had been part of “a pocket of under-immunized children in the community.”

Ms. Touma said the inoculation effort in Syria had made progress but was still failing to regularly reach an estimated 323,000 Syrian children at the highest risk of contracting polio, in areas of fighting or restricted access.

“The trick with polio is that we can’t give up, we have to do multiple inoculations continuously and as wide as possible,” she said.

Quote Collection:
Resurgent Measles Threat

Twenty-five years ago, the vast majority of measles cases were among elementary schoolchildren who caught it from their classmates, but that group now accounts for less than 10 percent of cases. Schools now require measles vaccine for enrollment.”

“Also, the disease is now attacking population groups that have not been vaccinated, perhaps through parental ignorance or neglect, or been exposed to the disease because of their age. Historically, deaths rates have always been high in such groups. Before the advent of a measles vaccine in 1963, virtually everyone could count on frequent exposure.”

“There were nearly half a million cases of measles nationally each year in the early 1960’s. The number of cases dropped to a low of around 2,000 in 1983, two decades after the development of a vaccine. But the disease began a dramatic comeback in 1989, and 1991 promises to be a bad year, particularly in the Northeast. New York City reported more cases in the first 12 weeks of 1991 than in all of 1990.” NY Times April 24, 1991.

Quote Collection:
Thanks to Anti-Vaxxers

“Measles has made a comeback, at least in New York City, where as many as 19 cases have been confirmed.

“New York City isn’t an anomaly, though. Diseases that are and have been avoidable in the U.S. thanks to vaccines, are resurfacing all across the country. Measles, for instance, was considered wiped out in 2000, but there have been several outbreaks in the past few years.

“Though measles outbreaks are primarily linked to unvaccinated people, McDonald notes that some vaccines aren’t foolproof. For example, the whooping-cough vaccine may lose its efficacy over time. And, overall, most people do get their vaccinations. A CDC report looking at children entering kindergarten for the 2012–13 school year in all U.S. states found that more than 90% of these kids had their vaccines.

“Still, there are people — including public figures and celebrities — who don’t vaccinate their kids and promote their choices. Most infamously, Jenny McCarthy has espoused her anti-vaccination position because she believes vaccines are full of toxins and cause autism. When she recently posed a question on Twitter about finding a mate, the vaccination backlash was loud and clear.

“Just how harmful are these notions, though? Below are some preventable diseases making a vicious return thanks to people not getting their vaccinations.

[Sections on measles, mumps, whooping cough, and chicken pox follow in the Time article.]

Purposeful Summary:
Dangers of Measles

According to the CDC, for every 1,000 children who get the measles, one or two will die. Currently, public-health workers are worried about the situation in New York, but just in the past three months, there have been reported cases of the disease in Massachusetts, Illinois and California. The CDC reports that from Jan. 1 to Feb. 28, 2014, 54 people in the U.S. have reported being infected with measles. On average, there are about 60 cases reported in the U.S. every year. Most people in the U.S. are vaccinated against the measles, but since measles is still around in other countries, those who travel outside of the U.S. can contract it if they are not vaccinated. New York City has not been able to confirm the source of the disease.

A Practice Opening

The proof that we will never eradicate polio from earth was evident at Disneyland in January, 2015. A measles outbreak there quickly spread, sickening 137 in California, and migrated to eight states and Canada. A single park visitor returned to Quebec and sparked an outbreak there that sickened 150 members of a religious group that shuns vaccination. Measles was banished from the US generations ago by the simple process of vaccinating children, but we have become complacent. Parents who thought they had little to fear have increasingly declined to vaccinate against a disease they haven’t experienced, creating the perfect conditions for measles to return.

Purposeful Summary:
How and Why of Polio

[consolidated encyclopedia information] Polio (short for poliomyelitis) is an infectious disease that rarely kills but cripples about 1 in 200 of its victims. The virus invades the nervous system and can lead to irreversible paralysis in just hours. Adults fight off the infection more effectively than children, most often children younger than five. There is no cure, but there have been safe and effective vaccines for more than 50 years. By their nature, vaccines need only be administered once to be effective for a lifetime, so the strategy to eliminate polio once and for all from the planet is to vaccinate every child until transmission stops. If the world can be made polio-free for a moment, it will remain polio-free forever.

The virus enters the body through the mouth, multiplies in the intestine, and is passed to others through the feces; therefore, it ravages particularly countries with poor sanitation and hygiene. Children not well toilet-trained are a danger, but even flies can passively pass the virus from feces to food. A single case of polio, if it fails to migrate to other vulnerable children, can die out in that community forever. Complicating matters, most infected individuals show no symptoms and can silently pass the virus on unwittingly until it dies out in their bodies naturally. Therefore, a single reported case is usually taken as evidence of an epidemic.

Purposeful Summary:
Effectiveness of Vaccination

[consolidated information no single source] A simple, inexpensive, oral vaccination developed in 1961, administerable by non-physician volunteers, is the primary method of preventing polio among children. The vaccination produces antibodies in the blood to all three types of polio virus which prevent the virus from spreading to the nervous system. A single dose costs less than a dime. In a community where the polio virus would be spread through feces contact, so can the immunization be passively spread through the same mechanism. A single dose protects most recipients. Three doses protects 95% of recipients, probably for life. 100% immunity, while ideal, is not necessary to eradicate the virus, which will naturally die out if it cannot spread through a population.

Counterintuitivity Note

In about 1 case per 3 million, the vaccine virus can itself cause paralysis. (A current theory is that paralysis results in recipients with existing immune deficiencies.) This risk, while devastating, is “accepted” by administering agencies as a necessary cost of saving “hundreds of thousands” of children each year from being crippled.

A Practice Opening

To rid the world of polio forever, we will have to paralyze 250 children. The tragic truth of our effort to eradicate polio using the most common and cost-effective vaccination technique (OPV) is that it paralyzes approximately one child in every 3 million inoculated. The cost of not vaccinating, of course, would be catastrophically higher, but we must nonetheless admit that we will be sacrificing some of the world’s children to achieve the goal of eliminating polio from the planet.

Purposeful Summary:
Counterintuitivity of Vaccination

The CDC reports 152 confirmed cases of paralytic poliomyelitis from 1980 through 1999 in the United States, an average of 8 cases per year. Six cases were acquired outside the United States and imported. The last imported case was reported in 1993. Two cases were classified as indeterminant. The remaining 144 (95%) cases were vaccine-associated paralytic polio (VAPP) caused by live oral polio vaccine.

In order to eliminate VAPP from the United States, ACIP recommended in 2000 that IPV be used exclusively in the United States.

Inactivated poliovirus vaccine (IPV) was licensed in 1955 and was used extensively from that time until the early 1960s.

Trivalent OPV was the vaccine of choice in the United States and most other countries of the world after its introduction in 1963. Use of OPV was discontinued in the United States in 2000.

Purposeful Summary:
Eradication Efforts

Polio was a most feared disease in industrialized countries, paralyzing thousands of children every year, until the development of vaccines in the 1960s and the beginning of routine immunization in countries around the world. From the Global Polio Eradication Initiative website:

In 1988, when the Global Polio Eradication Initiative began, polio paralysed [sic] more than 1000 children worldwide every day. Since then, 2.5 billion children have been immunized against polio thanks to the cooperation of more than 200 countries and 20 million volunteers, backed by an international investment of more than US$ 8 billion. Today, polio has been eliminated from most of the world and only four countries remain endemic. In 2009, fewer than 2000 cases were reported for the entire year.

What bad news does that terse report hide? The four endemic countries are Afghanistan, India, Nigeria, and Pakistan. But four other countries no longer on the endemic list have re-established active and persistent transmissions following an importation: Angola, Chad, Democratic Republic of Congo, and Sudan. Add to that the countries currently experiencing outbreaks due to importation (Congo, Kazakhstan, Liberia, Mali, Mauritania, and 8 others including Russia) and the challenge of containing the virus long enough to eradicate it becomes obvious.

Purposeful Summary:
Eradicability of Polio

Polio is a perfect candidate for eradication because the virus infects only humans, is carried in the body for a short period of time, and has an effective intervention. “We have great vaccines against polio,” says Harry Hull, chief of the World Health Organization’s (WHO’s) Polio Eradication Program. The WHO-led campaign uses the oral “Sabin” vaccine because it is cheap–8 cents a dose–can be easily administered by mouth by an untrained volunteer, and produces high levels of intestinal immunity.

IMPEDIMENTS TO ERADICATION
An editorial in the journal Lancet, SEP 2006, indicates that polio vaccination campaigns have met with distrust in communities over the years. Incorrect but understandable fears that mass vaccination is a conspiracy by the developing world against poor countries complicate the efforts of volunteers to conduct one-day mass immunization efforts which have been the most effective part of the WHO plan for years. Just as important as funding, volunteers, and sufficient doses, is building trust among poor and often suspicious people through sustained efforts.

STARTLINGLY EFFECTIVE SINGLE-DAY EFFORTS
FROM THE JOURNAL SCIENCE

One early morning, millions of people across India, from the snow-peaked Himalayas to the deserts of Radjastan, set off by foot, camel, bike, car, or helicopter to run polio vaccination posts in 650,000 Indian villages. By the time this army of volunteers arrived home at the end of the day, 127 million children under the age of 5 had been immunized against this crippling disease. “Everybody said it just couldn’t happen. And, yet it does,” says Harry Hull, chief of the World Health Organization’s (WHO’s) Polio Eradication Program. Initiatives such as the Polio Eradication Program show that WHO’s foot soldiers can make a huge difference to the majority of the world’s population without adequate health care.

A Practice Opening

If we ever banish polio from the planet, the heroes of that accomplishment will be thousands of volunteers who inoculate millions of children on a single historic day.

At first, the campaign to rid the world of a disease that has left some 10 million to 20 million people paralyzed did not seem to be making an impact. But in 1995, WHO and its partner, the United Nations Children’s Fund (UNICEF), adopted the new strategy of blitzing the entire child population of a country in a single day. In 1996, such National Immunization Days vaccinated more than 420 million children–almost two-thirds of the world’s children under five–against polio. These dramatic campaigns captured the imagination of the world and have even persuaded hardened fighters in war-torn countries such as Afghanistan, Sudan, and Sri Lanka to stop fighting for a day so that their children can be immunized.

Purposeful Summary:
Counterintuitive Setbacks

By the end of 2003, international effort had eliminated polio from all but 6 countries in the world. In the 6 remaining countries, the disease was highly localized. But a series of misunderstandings about the safety and intentions of the vaccinators shut down the campaign, caused a nationwide epidemic, and led to reinfection of many polio-free countries. For the first time in history, more countries suffered importations of polio than were actually endemic for the disease, putting the entire eradication initiative at risk.

In Kano, northern Nigeria, local leaders began theories that the vaccine contained HIV and anti-fertility agents. Very soon, the local media were reporting the popular conspiracy theory that the polio campaign was an effort to depopulate the north of the country. Within months, political leaders in Kano and adjoining states had suspended the polio campaigns; almost immediately, hundreds of children had been paralyzed as epidemic polio returned. The virus rapidly spread from Kano to the megacity of Lagos and beyond, reinfecting polio-free countries, costing over US $100 million in emergency response activities. One of Africa’s most impressive achievements in health and international cooperation was undone by a rumor.

Exercise E07: A Practice Opening

Let’s produce our own opening together using the preceding story of the counterintuitive setback as our prompt. By the end of class, produce a Practice Opening like those you’ve seen elsewhere in this White Paper. Add it to your post, “Polio Notes—Username.”

On January 15, 2004, the leaders of the World Health Organization and UNICEF met with the health ministers of the 6 remaining polio-infected countries and 3 of the recently reinfected countries to issue the “Geneva Declaration on the Eradication of Poliomyelitis,” stating that 2004 presented the best, and possibly last, chance to achieve this global public good. The declaration introduced an aggressive plan to immunize a total of 250 million children during door-to-door polio immunization campaigns in each country within the next 12 months. The Nigerian minister outlined an extensive program of joint work with Kano state authorities to resolve the remaining doubts about the safety of the polio vaccine and then allow the resumption of the polio immunization campaigns. In 2016, polio still exists in the world. Is the present moment, once again, our “best, perhaps last, chance” to eradicate the disease?

Purposeful Summary:
The Nagging Autism Case

From JSPN (Journal for Specialists in Pediatric Nursing): A decade ago, a British researcher and 12 coauthors published a paper describing abnormal gastrointestinal features among 12 children who had been referred to their clinic. All children had some type of developmental disorder, and in 9 of the children, a diagnosis of autism had been made. In 6 of the 9 autistic children, either the parent or a physician had linked the onset of developmental regression with the receipt of the MMR vaccine for measles, mumps and rubella (Wakefield et al., 1998). In 2000, a second paper was published, in which measles virus RNA fragments were found in 3 of the 9 children. (Kawashima et al., 2000). This odd, tiny, substantially anecdotal evidential link is the basis for fears persisting until today that somehow measles vaccinations cause autism.

In 2004, 10 of the 11 coauthors of Wakefield original paper asked to “formally retract the interpretation placed upon these findings . . .” However, these initial reports of a possible relationship between the MMR vaccine and the onset of autism received significant attention, and in England, measles vaccinations dropped considerably.

Working Hypothesis 1

Eradication is possible and highly desirable even if to accomplish it we need to be slightly unscrupulous.

Which openings so far have supported this hypothesis?

Working Hypothesis 2

The world is too fragmented and mistrustful to ever join in a truly global effort, even to eradicate a dreaded disease.

Which openings so far have supported this hypothesis?

THE SMALLPOX EXAMPLE:

A brief query of Rowan’s MEDLINE database yields 232 results for a simple search “smallpox eradication.” I suspect I’ll be able to find adequate historical information to support the theory that if any infectious disease can be eradicated from the planet (as smallpox was), then polio can be.

Topics for Smaller Papers

Distinguish Smallpox Eradication from Polio Eradication

(Definition/Classification Argument)

If there’s a class difference between polio and smallpox that interferes with this conclusion, I may be able to devote one of my smaller papers to detailing that difference, either to minimize it or to recommend a different approach for eradicating polio than was successful for smallpox.

Compulsory Vaccination Will Be Required

(Cause/Effect Argument)

Regarding the successful eradication of smallpox from the planet, an article in the May 8, 2010 Lancet offers insight I may need to use.

Force was, of course, sometimes used to achieve immunisation [sic] targets…. Organised [sic] and violent resistance during epidemics could provoke ferocious responses from vaccination teams…. Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge, and this was seen as sufficient justification for the use of compulsion. Compulsory vaccination schemes were implemented with the assistance of police and paramilitary forces which had considerable societal support.

Current State of the Research Paper

The thrust of my research continues to convince me that the effort to once and for all eradicate polio from the planet is a worthwhile and achievable global good. I will propose continued and even stepped-up efforts to eliminate this virus from the planet once and for all, despite excellent arguments to the contrary.

Counterarguments:

  1. the money could be used to alleviate more suffering more immediately by attacking less recalcitrant diseases;
  2. that human beings will never universally accept the necessity and efficacy of the effort and will therefore sabotage the effort;
  3. that eradication is a myth since new strains will always replace the old before the old dies out.
  4. that resistance will build based upon the awareness that many children will be infected, some paralyzed, some even killed by the eradication effort.

Arguments:

  1. I feel strongly that the tiny risk of transmitted paralysis to one child in 3 million is “acceptable,” God forgive me for saying so.
  2. I also insist that it might be necessary to compel the reluctant last however-many-thousands to submit to vaccination against their wishes.
  3. I recognize the moral dilemma, but think it might be forgivable to lie about that tiny risk if to do so put a rumor to rest that threatened the entire program.

Further Reading:

  1. The success rates of various vaccines (there are four);
  2. more opinions on the origins of the Nigerian rumor (there are many);
  3. details of the life-cycle of the poliomyelitis virus (when will we know it’s really, really gone for good?);
  4. ancillary techniques for immunization (can we use bad sanitation to our advantage?).
  5. I love the counterintuitive result that immunization can be spread accidentally the same way the virus is spread!