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Prevention at what cost?

Ten-year-old Ryan Kress is bouncing a tennis ball against his living room wall and fielding it off the carpet. He stops long enough to say that he hopes someday to "play baseball for a major league team."

"A lot of kids have that wish," his mother, Carolyn Philips says. "But they have a chance."

Ryan does not.

He contracted polio as an infant from the standard oral vaccine.

That is the way it has always been for Ryan: Some of the biggest decisions in his life _ including what he can and cannot do _ have been made for him in the offices of drug companies, government agencies and in courtrooms.

His illness is a direct result of a national immunization policy that is more than 30 years old. And, though most people are unaware that polio still exists in any form, some of those who know most about the disease consider the oral vaccine unnecessarily dangerous.

This is what Ryan's lawyers have argued in a legal fight for compensation that is almost as old as he is. But so far, he has received very little compared to others with similar cases. It's not enough money to support him into adulthood. It doesn't nearly make up for all the limitations in his life.

Praise for the polio immunization program _ as well as the virtual canonization of the recently deceased Jonas Salk, who developed the first vaccine _ is understandable to those who remember the terrifying summer epidemics after World War II.

Magazines ran pictures of gymnasium-size hospital wards crowded with young patients in iron lungs. Parents forbade children, the most susceptible group, from going to the beach or to theaters. Students who ignored these warnings, healthy in June, would return to classes in the fall walking with crutches or carrying an arm in a sling.

In the worst year, 1952, polio infected 57,879 people, 3,145 of whom died from it, according to the federal Centers for Disease Control and Prevention (CDC).

Many who did not die were permanently paralyzed; the contagious virus essentially kills the parts of the nervous system that coordinate muscles.

"The illness begins with headache, fever and stiff neck," according to a CDC report. "This is followed by paralysis of the voluntary muscles previously controlled by the destroyed neurons of either the spinal cord or the brain stem."

Salk's injected vaccine was first distributed in 1955. Albert Sabin's oral vaccine, cheaper and painless, was introduced in 1961. The number of polio cases in this country fell to fewer than 1,000 in 1962 and below 100 in 1965. The United States reported its last case of naturally contracted polio in 1979.

But every year after, the CDC continued to record small numbers of new cases _ 12, nine, eight, five _ a total of 116 between 1980 and 1993. All have been caused by the oral vaccine. According to CDC scientists, they are an acceptable consequence of such a widely beneficial immunization program.

Acceptable, unless like Ryan, the single dose you ingest as an infant disables you for life.

And acceptable, maybe, if the risk were as low as the CDC claims, or if the oral vaccine were the only option, said Ryan's current lawyers, Marc Moller of New York, and Stanley Kops of Philadelphia, both of whom have devoted their recent careers to polio cases.

But an entirely benign vaccine has been available for 40 years, and, they say, government statistics about the safety of the oral vaccine are misleading and incomplete.

The oral vaccine is made of a weakened but still living virus. For unknown reasons, a small percentage of otherwise healthy infants who are infected with it are stricken with the disease. Recently vaccinated babies shed the virus in their feces, so inadequately immunized adults can also get polio from handling them.

But, because of the government's recommendation, the oral vaccine remains the overwhelming choice of pediatricians; it is administered in this country more than 100 times as often as the injected one.

Medical opinion, though, is by no means unanimous on this issue.

"We have 10 or 15 kids a year getting it from the (oral) vaccine," said Dr. Lauro Halstead, director of polio research at the National Rehabilitation Hospital in Washington D.C.

"One kid is too high a price to pay if there is a safe alternative, and many other countries use it."

That alternative is an updated version of the old Salk vaccine, which cannot cause polio because it is made from dead virus. A CDC pamphlet about the two vaccines lists, as the hazard of the injected vaccine, "mild soreness where the shot is given."

So, it is not a matter of finding a safe vaccine, Kops and Moller said, it's a matter of paying for it.

"This move to live polio vaccine was economically driven," Moller said. "It was unnecessary, and in fact unconscionable."

The oral polio vaccine is taken in a series of four doses, usually starting when babies are two months old. The first of these, because the body has not yet been exposed to the virus, poses the greatest threat.

Dr. William Atkinson, a medical epidemiologist with the CDC's national immunization program, put the risk of getting the disease from this first dose at 1 in 1.8-million. The CDC pamphlet on the vaccines says it is 1 in 1.5-million.

But these numbers include only normal children such as Ryan. They do not include immune-deficient babies or the adults who contract polio from recently immunized infants. If these cases are included, the first dose of this vaccine causes a case of polio every 520,000 times it is administered, according to CDC documents.

Kops, Ryan's attorney, said even this number is far too low because it includes only the cases recognized by the CDC, a list he knows is incomplete because many of his clients with proven cases of polio have not been on it. The real risk is about one in every 200,000 doses, he said.

Atkinson said the oral vaccine has an added benefit of preventing people from later being exposed to polio and becoming uninfected carriers of the disease. But he essentially agrees with Moller; price and convenience are the primary advantages of the oral vaccine.

The government pays $4.50 for each dose of injected vaccine, compared to $2.21 for the oral one. Very little expertise or time is needed to administer the oral form. Considering that "tens of millions of doses are administered every year . . . it could save $40- or $50-million," Atkinson said.

This could finance, for example, 400,000 vaccinations for hepatitis, which kills about 5,000 people per year.

"This gets into some public health philosophical issues," Atkinson said.

A week or so after taking the first dose of the oral vaccine as a 3-month-old in St. Louis, Ryan developed a fever of 102.8.

Philips, then a 20-year-old single mother, took him to the hospital where he had been born. A doctor there told her it was a recurrence of Ryan's earlier ear infection, prescribed antibiotics and sent him home.

A week later, when Philips was changing Ryan's diaper, she noticed his left leg seemed flaccid. The next morning, she said, "he was completely limp all over. I told my mother, "He almost looks dead.' "

Philips suspected the vaccine. But the doctors refused to consider polio when diagnosing Ryan, she said. Or, if they did, they didn't tell her.

"In 1985, or 1995, no one is looking for polio," she said.

Philips was told Ryan had a milder paralytic condition, Guillain-Barre syndrome, and that with physical therapy he would recover in 6 months. When he was no better after a year, she said she was repeatedly advised to "wait and see."

"As a parent I did not want to wait and see . . . When I went to the park, I was carrying Ryan and I could see babies his age walking around and toddling," she said. "I knew there was something wrong, bad."

By then she had already begun the ill-fated legal fight on her son's behalf. Partly because of the approach taken by her former lawyers and partly because of bad luck, Ryan is one of the least-compensated of the people who have been permanently disabled by vaccine-related polio.

The demands of the litigation and of caring for Ryan forced Carolyn Philips to quit her job as a supermarket manager. She married Nick Philips, a registered nurse, when Ryan was 2. They moved to Clearwater about four years ago, and to Hernando County last year.

Not until Ryan was about 5 did his lawyers discover that the hospital told the CDC what it never told Philips. Ryan had a confirmed case of polio that could be traced directly to the vaccine.

Ryan's lawyers settled with the vaccine's manufacturer, Lederle Laboratories Inc. in 1993, accepting only $50,000 because they could prove no negligence.

The case against his health maintenance organization, Group Health Plan of Greater St. Louis, went to trial later the same year.

Shortly before the jury returned a verdict, Group Health lawyers offered Philips a high-low deal. It meant that if the jury found the company negligent, the maximum award would be limited. If the jury found no negligence, Ryan would be guaranteed of a minimal payoff.

Philips agreed to the deal to ensure that Ryan received some compensation. The jury cleared Group Health.

The agreement prevents Philips from telling the amount of that settlement. She can say, though, that it's only a fraction of $1-million and a tiny fraction of what some other polio patients received.

Ryan's case "is worth multimillions of dollars," Moller said. "His settlement is peanuts . . . It's a travesty."

What Ryan's former lawyers did not know about, but should have, was a 1991 case argued by Kops and Moller.

Federal District Judge J. Motz ruled that the Division of Biological Standards, now a part of the Food and Drug Administration, had allowed the vaccine to be released although it did not meet its own standards.

This ruling was the basis of later settlements between $2-million and $5-million. One of Kops' clients, another boy from near St. Louis about Ryan's age, received $16-million.

Ryan's former lawyers could have found out about it by running a routine computer check. Carolyn Philips learned of it by reading the newspaper shortly after her 1993 trial.

If they had known about it just a few months earlier, it would have drastically changed the way they approached the case, especially their dealings with Lederle, the vaccine's manufacturer.

Now it is probably too late.

Moller and Kops cannot sue the FDA, which has paid the largest settlements, because Philips' former lawyers advised the family against it years ago, allowing the statute of limitations to expire.

The settlement with Lederle forbade any further claims against the company. Kops and Moller have been trying to get Missouri courts to overrule this stipulation, saying the family settled only because it knew nothing of judge's Motz's decision.

A lower court agreed with them, but successive rulings have gone the other way.

"Lederle's still winning," Philips said.

There is no noticeable air of tragedy in the Philips home. The family lives in a mobile home now and are building a house on five acres of land they bought in December.

The foundation of the home, with wheelchair ramps, is in place. Ryan can look through the square gap that will be his bedroom window and see a sloping cow pasture and, beyond it, the Withlacoochee State Forest.

He has the good-looking, cheerful face of a poster child, which he was in St. Louis. He has three dogs, including a Jack Russell mix named Patches who likes to jump into his arms. "They're in love," his mother said.

He can field a ball better on his calloused knees than most children can on two good legs. With his braces on he can walk. He goes to private school with children his age. He can mow the lawn on a tractor and ride a horse by holding tight to the saddle horn.

"He just goes, goes, goes," his mother said.

"I'm so rough on my braces that the bolts keep breaking every other day," he said, pleased with himself.

But polio has affected every part of the family's life.

Nick Philips said that before he married Carolyn, people gossiped that what he really wanted was a share of Ryan's anticipated settlement. Carolyn Philips' former lawyers made him sign a prenuptial agreement to ensure that he would not get it.

Their relationship still suffers because Mrs. Philips sometimes devotes less time to it than she does to the lawsuits. "I get too involved with it," she said.

And despite all the things that Ryan can do, there are many things he would desperately like to do that he can't. It's a task to walk up the slope through the grass from the mobile home to the home site. Hiking in the forest he can see from there is out of the question.

Most of the time when he is at home he doesn't wear his braces and walks on his knees, holding his useless left foot in his left hand. His mother has yet to find a little league team that will let him play.

He is becoming more aware of his limitations as he matures, his mother said.

"The other day he said to me, "I wish for one day _ just one day _ I could run like a normal kid,' " she said.

As he grows older, he is in danger of post-polio syndrome, which can sometimes be fatal. Polio patients are most severely affected when the disease first strikes. They can recover for a limited time, after which their condition reaches a plateau, Halstead, the polio researcher, said.

As yet, there is no medical procedure that offers any hope for significant recovery.

"When you see Ryan now, you are seeing the best day of his life," Kops said.

Philips admits that this sometimes gets her down, especially when she thinks about it all being due to a single dose of what seemed to be the most harmless of the childhood vaccines.

She wants other parents to know that the risks of the oral vaccine are not quite as negligible as doctors or nurses would have you believe. What seems negligible to her now is the pain and expense of the injected vaccine.

"What I would tell new parents is, "No live polio vaccine. No live polio vaccine, period, end.' "

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