This series is hosted by FACE (the Focus Area for Compassion and Ethics) for sparking discourse and awareness through examination of provocative ethical questions in global health.
Overview
The Task Force for Global Health upholds compassion as one of our four core values.
Founder, Bill Foege, was speaking of this compassion when he reminded his
colleagues, “in everything we do” we must “see the faces.” We must welcome the
emotional connection that we share with our fellow humans. You can see this quote in
the lobby of the Task Force.
Yet to be effective as global health practitioners, we must also pay attention to the
numbers – examine health across populations. So, what does it really mean to “see the faces?” How should it influence data interpretation, decision-making, or program and policy development? When, if ever, does “seeing the faces” distort our ability to “see the numbers” too?
To help us explore these questions, we welcomed Dr. Walter Orenstein, an expert in
vaccine-preventable diseases, to this FACE Ethics Lunch & Learn (L&L). Dr. Orenstein shared how an experience of “seeing the faces” was an important catalyst behind the
policy change that moved the United States from using oral polio vaccine (OPV) to
inactivated polio vaccine (IPV). OPV is uniquely effective in stopping person-to-person spread of poliovirus, easier to administer, and much less expensive. But, rarely (1 case
per 3 million doses), OPV is associated with vaccine-associated paralytic polio (VAPP).
In this L&L, we heard how the public testimony of those with VAPP offered Dr. Orenstein an opportunity to “see the faces.” This increased his sense of urgency for shifting from OPV to IPV, and subsequently influenced United States public health policy. We also reflected on our experiences at the Task Force of “seeing the faces” and discussed what such experiences mean for us as a value-centered organization.
This was the third L&L in a four-part series on the Task Force’s core values: collaboration, stewardship, consequential compassion, and global health equity and social justice. This report summarizes the key points from Dr. Orenstein’s interview
(accessible to staff here).
Introduction and Framing
FACE leaders, Ashley Graham and David Addiss, introduced the event by describing the components of compassion: awareness + empathy + action.
It is often through a personal encounter – “seeing the faces” – that we become aware of suffering and experience empathy for those who suffer, which generates a desire to act to alleviate or prevent that suffering.
In 2017, Dr. Orenstein briefly relayed his transformative experience in the “We Were There” video series, produced by the Centers for Disease Control and Prevention (CDC). In this video, at segment 1:05:21 – 1:06:01, you can hear Dr. Orenstein’s description of “seeing the faces” at the 1996 meeting of the Advisory Committee on Immunization Practices (ACIP). Segment 1:13:30 – 1:14:27 summarizes the implications of his experience. The L&L participants viewed these clips before David interviewed Dr. Orenstein.
Highlights from Dr. Orenstein’s Interview
Dr. Orenstein began by summarizing the advantages and disadvantages of OPV relative to IPV. OPV is considerably less expensive, provides superior community immunity, and – because it is an oral vaccine – can be delivered easily in remote areas. Unfortunately, however, the live virus in OPV can revert to a form that, albeit rarely, causes paralysis. In contrast, IPV is highly effective in protecting the individual vaccine but is less effective in protecting the community. And, it does not cause VAPP.
By the mid-1990s, transmission of wild poliovirus had been interrupted in the United States, but continued use of OPV resulted in 8 – 10 cases of VAPP each year. The United States had already established a Vaccine Injury Compensation Program, which provided financial support and other resources to persons with VAPP. Yet, although this program was itself an expression of communal compassion, it did not prevent new cases of VAPP and could never restore full health to those who were affected.
At the time, only a few countries had shifted from OPV to IPV. One of these countries was Israel, where a polio outbreak occurred. Although the scientific community was divided on the cause of the outbreak, it heightened concern that switching from OPV to IPV could reintroduce outbreaks of wild poliovirus in the United States. As Director of the United States Immunization Program, Dr. Orenstein was responsible for preventing such outbreaks, which could result in many more cases of paralytic polio than VAPP. As a scientist, a vaccine expert, and a public health official, it was not clear to him that the benefits of switching to IPV – and preventive VAPP – outweighed the risks of wild polio outbreaks.
But, as Dr. Orenstein describes, at the 1996 ACIP meeting, “the room was packed with children with vaccine-associated paralytic polio. Suddenly the 8 to 10 cases a year, instead of being small numbers, became real people. And looking at their faces, and understanding how hard their lives were, when they had a perfectly safe alternative – inactivated vaccine – switched me overnight from being worried about a change to ‘we’ve got to make a change’.” This experience of “seeing the faces” transformed Dr. Orenstein, in his words, “from an OPV hawk to an IPV hawk. There were issues of expense and whether the community would be adequately protected with IPV, but I thought for moral and ethical reasons that we had to go to IPV.”
While the scientific data had not changed, Dr. Orenstein’s powerful experience of “seeing the faces” prompted him to weigh the risks and benefits from a new perspective. This was not his first experience of “seeing the faces.” As a young boy, he had personally witnessed the ravages of polio on the central nervous system, which both motivated him to enter medicine and public health. These earlier experiences of “seeing the faces” also impressed upon him the high stakes of making the right decision and doing everything possible to prevent polio outbreaks.
Working quickly and effectively through layers of bureaucracy, Dr. Orenstein channeled his growing awareness and empathy, as well as his position of influence at CDC as Director of the National Immunization Program, to act. He and his colleagues recommended a sequential immunization approach, in which children would first receive 2 doses of IPV and then 2 doses of OPV. This approach would both provide community protection and avoid VAPP. Yet, because many pediatricians already had OPV in their offices and continued to administer it, cases of VAPP also continued. To prevent any further potential VAPP cases, Dr. Orenstein supported a policy switch in 2000 to a full IPV regimen.
Fortunately, the switch to IPV did not result in new outbreaks of wild poliovirus, and immunization coverage with IPV did not markedly decrease from levels with OPV, as had been feared. Indeed, the switch to OPV likely helped to instill confidence and trust in vaccines, since the risk of VAPP had been eliminated. Yet there was an economic cost to the US public. Analyses by CDC economists estimated that switching to IPV cost US taxpayers $28 million per year [1].
Some ethicists and many public health professionals argue that public health decisions should be based solely on data – that there is no place for emotion or personal relationships in public health policy. Dr. Orenstein affirmed the importance of science in understanding context, and vice versa. In 1996, there was no doubt that VAPP was causally related to OPV and that wild poliovirus had been eliminated in the Americas, thereby reducing – but not eliminating – risk of wild polio outbreaks, since transmission continued in other areas and the virus could be imported. And, if outbreaks had occurred with the switch to VAPP, scientific investigation would have been essential in determining whether the switch to IPV was, in fact, the cause.
But Dr. Orenstein also affirmed the importance of empathy, of shared humanity, in public health policy. He reflected, “As opposed to what I initially thought were trivial numbers, these were not trivial people. Seeing them changed my thinking. I could have been wrong – outbreaks may have occurred with the switch to IPV – but I thought we needed to take that risk…I also tried to think about what I would want for my child. I would want IPV rather than OPV, to not take a chance [with VAPP].”
In closing, Dr. Orenstein stated, “It is very important to put faces on numbers. To make them meaningful.” Looking ahead to future applications of vaccine safety and the present lack of public trust in vaccines, he recommended being aware of the everyday effects of public health policy, for example, via implementation science. He also emphasized the importance of communication. “You need the right message, delivered by the right messenger, delivered through the right communication channels,” and you can only know this if you truly see and listen to affected communities.
Miller, M. A., Sutter, R. W., Strebel, P. M., & Hadler, S. C. (1996). Cost-effectiveness of incorporating inactivated poliovirus vaccine into the routine childhood immunization schedule. JAMA, 276(12), 967–971. https://pubmed.ncbi.nlm.nih.gov/8805731/
Guided Reflections
To help Task Force staff reflect on Dr. Orenstein’s testimony and their own experiences, and to consider the broader importance of compassion as a value at the Task Force and in global health, Kenya Casey, Deputy Chief Operations Officer, guided staff through a series of questions:
Dr. Orenstein’s story
- What thoughts and feelings arose when you heard Dr. Orenstein describe his experience of ‘seeing the faces’?
- What questions would you like to explore with him?
Your experience
- Is there a particularly memorable experience you’ve had of ‘seeing the faces’? What was that experience like for you?
Seeing the faces in global health
- How does your role or position at work influence your ability to ‘see the faces’ and act with compassion?
- How might we further nurture compassion as a Task Force value?
- How might we more clearly ‘see the faces’ of our colleagues at the Task Force?
Staff Questions and Reflections
Staff shared reflections and asked Dr. Orenstein several questions about the challenge of “seeing the faces” and “seeing the numbers” at the same time. How should we make decisions when the trade-offs involve not only health-related risks and benefits, as with OPV vs. IPV, but also, as with COVID, consequences like social isolation and economic loss? And, if we cultivate our capacity for “seeing the faces” and for empathy and compassion, how do we manage our moral distress when we are not able – as Dr. Orenstein was – to affect policy or relieve suffering? In both cases, a full willingness to see and listen alone to the perceived grievances of those impacted may itself be a compassionate act, or at minimum, inform the most useful ones to come.
We wish to especially thank Dr. Orenstein for sharing this experience and its long- term implications, Kenya Casey for guiding staff in their reflections, and Task Force staff for engaging in co-learning. We look forward to seeing you at our next FACE Ethics Lunch & Learn on the last Task Force core value: global health equity and social justice. If you have missed any of our prior webinars, you can view their reports on our website.
