Dr. William Schaffner



TORGHELE: Today is December 6, 2018, and we are at Vanderbilt University with Dr. William Schaffner who is Professor of Preventive Medicine in the Department of Health Policy and Professor of Medicine in the Division of Infectious Diseases at the Vanderbilt University School of Medicine here in Nashville, Tennessee. He was also an Epidemic Intelligence Officer [EIS] at the Centers for Disease Control and Prevention [CDC] in 1966 and ever since then he has been such a fan of CDC that he cannot tear himself away and he would be the biggest fan of CDC there is here at Vanderbilt. So, we will talk more about that as we get to know him in the interview. I am Karen Torghele, and I'll be talking with Dr. Schaffner for the Global Health Chronicles Oral History Polio Project. First of all, I want to thank you Dr. Schaffner, for agreeing to be part of this project.

SCHAFFNER: Karen, it's wonderful being with you. Thank you. In fact, it's an 00:01:00honor to be with you because CDC's role in polio elimination, shall I say eradication, is just terribly important.

TORGHELE: Thanks so much. So, I understand that you have some childhood memories about polio and getting vaccinated.

SCHAFFNER: Well, back in the day when I was very much in very short pants, I do remember being vaguely a polio pioneer, being in line with my parents waiting for oral polio vaccine and getting it on a sugar cube. And then fast forward--I remember vaguely being in college and being asked to go to the student health service, we all were, to get a polio vaccine booster and that was also oral polio vaccine. So, the memories do go back, but they're a little vague--but I was protected very young.

TORGHELE: Did you know people who had polio?

SCHAFFNER: Actually, I had a cousin who had poliomyelitis. He had a mild case, some paralysis in one of his legs and he had very little. He was fortunate, he had very little residual paralysis--so little that he was actually able to serve in the United States Navy, so he did very, very well. But I do remember the era where I wasn't allowed to go to public swimming pools in the summer, restricted somewhat in playing with my playmates and, of course, there was a lot of fear, a lot of anxiety about poliomyelitis generally in the community. And I also remember the March of Dimes and those cardboard displays in various stores that I went to and I remember saving the dimes to put into the display.

TORGHELE: That was a big deal.

SCHAFFNER: It was a big deal, and it made us all participants. It made us all grantors, right? It made us all support the research in the clinical care. It was one of the things that we don't see so much in the contemporary society. But this was all something we worked together to support. How different sometimes from the response to vaccines that we get today. We actually helped pay for the research that developed the vaccine. And then, of course, the vaccine was so well accepted initially when it came out, the lines went around the block, of parents bringing their children to be vaccinated. There was a fear of the disease and therefore a high value for the vaccine.

TORGHELE: Do you have any memories of when the first vaccine was announced, that 00:04:00there was something for polio?

SCHAFFNER: I don't have any specific memories of that. I think most of my memories come from reading and being aware of what went on then, but I think that's a learned memory rather than an active memory of my own.

TORGHELE: What I wanted to know, too, about your background is how you got interested in medicine.

SCHAFFNER: Well, I'm the son of immigrants, the first son born in the United States and so I had no precedent for medicine in my family, but I do remember the family doctor, Dr. Tidwell, who came to visit me when I was sick, with his large black bag and I remember going to his office. He lived literally above his 00:05:00office, and I remember still the smell of disinfectant which permeated his office, and somehow I decided that's what I wanted to do.

TORGHELE: Tell us where you grew up and where this all happened.

SCHAFFNER: This all happened across the river from New York City in northern New Jersey in a community called West New York, and I lived in a congregation of folks who were really immigrants to this country and so there was always a profusion of languages that were spoken in the homes of my friends when we went to visit. Lots of Italians--these were not the fancy Milanese, but these were the Neapolitans and Sicilian families, and there were many Jewish kids and they spoke often several languages in their home, Eastern European peoples. Our language, second language, was German. As I like to remember, we felt sorry for 00:06:00the Irish kids. Can you imagine? They only spoke English at home. So, it was a very diverse first generational kind of lower middle-class neighborhood that I grew up in.

TORGHELE: Sounds like a rich environment.

SCHAFFNER: Oh, yeah, it was great.

TORGHELE: And were you a good student?

SCHAFFNER: I was a good student, yeah. I worked hard. First born in the United States. Report cards were very important, and if there was anything much less than an A, there was a question about why we didn't study hard enough, yeah. So, scholarship, working hard was very, very important, was highly valued in the family.

TORGHELE: So, your parents encouraged you in your studies.

SCHAFFNER: Oh, yes. They not only encouraged studies, they insisted on it.

TORGHELE: I was being gentle there.

SCHAFFNER: Yeah.

TORGHELE: So, when you were in college, did you know then that you wanted to go into medicine? Did you know all along?

SCHAFFNER: Somehow it started in grade school, and it carried through to high school. That's why I studied Latin. Back then you thought that you had to study Latin as a pre-med somehow. So I studied Latin in high school and went to college really as a premed from the moment I walked in the door and I never wavered from that very much, although there was a time when I was seduced a little bit by theater and things like that and, well, I've tried to integrate those things because I work with the media and try to educate people through the media about medicine and developments in infectious and communicable diseases, and so I've tried to marry those two interests.

TORGHELE: That's a good way to do it.

SCHAFFNER: Yeah, it's been successful, I think.

TORGHELE: Now, I mentioned in the introduction that you were at the Centers for Disease Control and Prevention in the Epidemic Intelligence Service. How did you become involved with CDC? How did that come about?

SCHAFFNER: I became involved with the CDC--I learned about the CDC when I was in medical school. I actually was encouraged to sign up for a subscription to the MMWR [Morbidity and Mortality Weekly Report]. I remember reading it weekly as it came out and said, gee, that really attracted me--that kind of work. And then I met the Chief of Infectious Diseases in the Department of Pediatrics at Cornell University Medical College, Heinz [F.] Eichenwald, and Dr. Eichenwald was an EIS 00:09:00alumnus. So he introduced me to the concept of the EIS and what EIS officers did and suggested that I apply and so I did because we were all subjected, of course, to Selective Service, the draft. You had to serve. I was more than happy to serve but here was an opportunity for me to serve in a function that I thought benefitted all of society and just revved my infectious disease motor which obviously I was very attracted to early on. So, I applied and remember being absolutely thrilled when I was accepted and immediately informed my local draft board that I now had been offered a commission in the United States Public Health Service, thank you very much, the Army doesn't need me, but the Public Health Service does.

TORGHELE: That must've felt good.

SCHAFFNER: Yeah, it did feel good. It felt great.

TORGHELE: How long were you at the CDC?

SCHAFFNER: I was at the CDC as an employee of the CDC as a Commissioned [Corps] officer for two years, and then I became part of the Commission Reserve [Corps] and I laugh because I'd been at the CDC so often since working on a variety of different projects and the Advisory Committee on Immunization Practice [ACIP], I almost think I ought to have a little apartment across the street from the CDC because I'm there so often. I mean my work with the CDC as an EIS officer changed my career. It just fueled my interest in infectious diseases and permitted me to marry my interest in clinical medicine and academic medicine and public health, and I've had this opportunity to have a foot firmly in both camps and bring them together, and for that, I am forever indebted to the CDC. It's 00:11:00been a remarkably rewarding career.

TORGHELE: Would you tell us a little bit about your assignment when you were an EIS officer?

SCHAFFNER: I knew during EIS week, during the conference when we were interviewing for various positions, already that I was pretty sure I was going to be in academic medicine, so I had decided I wanted to see what was going on outside. So, I was really most attracted to work in the state health department, and I was selected. I was matched to go to the Rhode Island Department of Health to work in their health department, and the nice thing about the Rhode Island Department of Health is there was only one health department in Rhode Island. City, county health departments had been eliminated so there was only the State Health Department. There was a population of, if I remember correctly, about 910,000 people and I remember driving from Connecticut into Rhode Island to my 00:12:00assignment in my little VW thinking, "I now have 900,000 people in my practice." We were a little cocky back then, but that's the way it developed, and I had a wonderful time at the Rhode Island Health Department. No matter where the outbreak was, I could be home for dinner.

TORGHELE: That's right. Can you remember some of the outbreaks that you dealt with?

SCHAFFNER: Well, the main thing that happened that introduced an internist studying individual patients, because I'd already had my infectious disease fellowship, particularly with the diagnosis and treatment of bacterial disease. The thing that transformed that kind of personal medical interest into the prevention of pediatric viral infections via vaccines was measles because my 00:13:00predecessor, [Dr.] Beryl [J.] Rosenstein, had worked with the state epidemiologist, [Dr. James E.] Jim Bowes, and others on conducting a statewide mass vaccination campaign against measles for the entire state's children. And this was something that was not in the CDC's playbook but was something that Jim Bowes promoted--mass campaigns, and he was a masterful organizer of those, and one of the reasons he was so successful is that he didn't take credit for it personally or give the state health department credit. He made it a program of the Rhode Island Medical Association and more importantly a major project of the medical association's auxiliary. They had one major project that year, and they adopted this mass campaign, and so he organized that on a weekend in January, I 00:14:00think it was a Sunday, that people would go to vaccination stations throughout the state, bring the children to be vaccinated. He had to organize all of that. You can imagine all the personnel at the clinic. Toward the last days just before the campaign, he expressed the concern to the president of the auxiliary that so far, they hadn't been able to recruit enough doctors to staff those clinic sites because you had to have a doctor there even though nurses were administering most of the vaccines. They were injectable vaccines, of course. And the auxiliary chief, the president of the auxiliary looked at him for a moment, so the story goes, and said, "Dr. Bowes, don't you worry, all the doctors will be there." So, the ladies got all their husbands--because most of 00:15:00the doctors then were male--the ladies made sure that the doctors were staffing their clinics for their major project of the year. It went off flawlessly in the midst of a blizzard. And I did a back-of-the-envelope calculation and said that somewhere between 20 and maybe 30 percent of the entire state's population in the middle of a blizzard was all working on that Sunday to contribute to this huge preventive medicine immunization effort. Just extraordinary. And so, the immunization rate in Rhode Island among our children went from very low levels to very high levels. That's been recorded in the literature. My job--I mean that's what they did.

So, I came in later. Measles elimination was very much on everyone's mind. It 00:16:00was a high priority then, and I said, "Gee, they've done everything. Oh, what I'll do is set up a surveillance system for measles to evaluate the impact of that mass campaign." So, we made measles a reportable infection by phone to the state health department, and we really promoted that among all the doctors and all the nurses in Rhode Island. But when we got a call that there was a suspect measles, the public health nurse, Rita [M.] Adair, and I immediately got into our car, drove to the doctor's office where the patient was or to the patient's home, interviewed and examined the patient ourselves, with permission drew acute bloods and then came back later to draw convalescent bloods to document the occurrence of measles. And what we documented is that in our large highly 00:17:00immunized population the only children who got documented laboratory-confirmed measles were children who had missed the mass vaccination campaign who either had visitors from outside the state who brought measles to their home, or who had themselves gone out of state and acquired measles, and there was no spread of measles to other Rhode Island children who had contact with these children who had measles. There were very few. This was proof of concept that in a large geographic area with a large population, over 900,000 people, you could immunize that population, the immunity would be solid, so the whole concept of measles elimination was validated and encouraged. It was great, and since then, I've 00:18:00been associated with vaccines and the dramatic impact that they can have on the health of large populations. This continues, and I look forward to even more vaccines in the future but it also, in the present environment, breaks my heart that there would be parents who would withhold their children or have serious questions about the importance of vaccines. I mean vaccines have just changed our whole concept about the fragility of children growing up and the diseases that they're associated with. But we're prisoners of our own success. We've eliminated the diseases, and now the parents don't know the diseases, so they don't respect the disease or even fear it, so they have a harder time valuing 00:19:00the vaccines.

TORGHELE: We'll talk about that more as we go on, but I wanted to also see what you did to sort of advertise what Dr. Bowes did in Rhode Island by writing about it.

SCHAFFNER: Well, all that experience was brought together, and it was my first major paper which was published in the New England Journal of Medicine. Wow, was I proud about that. And it was the "Clinical Epidemiology of Measles in a Highly Immunized Population." That's probably the title. I think that's the correct title of the paper. So, we were very pleased to publish that. That was a major paper that came out of that experience.

TORGHELE: So, you did a lot to promote vaccination by doing that.

SCHAFFNER: Sure. I think that paper helped encourage measles vaccinations in 00:20:00many other states because it just validated the concept that you could indeed solidly immunize a large population, and even if you had a little bit of introduced or residual measles, it wouldn't spread. The protection afforded by the vaccine was solid. We had no spread.

TORGHELE: It's a miracle.

SCHAFFNER: It's a medical miracle, and it's the product of an awful lot of hard work.

TORGHELE: So that tells us how you got involved with prevention and immunization and how that became sort of your focus in your career. Are there other things that happened when you were an EIS officer that led you to focus on your career as it is now?

SCHAFFNER: Well, I had a whole series of wonderful experiences as an EIS officer. One of the things I was privileged to do was to be part of a CDC team. 00:21:00A number of us EIS officers were recruited to actually go to India and assist in a malaria eradication evaluation team along with the World Health Organization. We were all brought together to Atlanta, were given a whole day's worth of instruction, education about malaria eradication, how it was organized and how it was evaluated. We were sent to India. We then all of us--I think there were about six of us who were sent on different teams around the country--evaluating the progress of different geographic areas in India as they approached malaria eradication, and we went deeply into the field. I mean we went as far as our vehicles could go and then we went on donkeys to villages where I'm sure I was the first Westerner that the people in the village had seen, evaluating the 00:22:00malaria eradication activities. And what we had learned as very young EIS officers was immediately applicable in evaluating malaria eradication. And then, of course, on the way back as we went back to Delhi at the completion of our field assignments. Somehow the conversation in the jeep turned to smallpox and since I was the resident CDC expert, I was asked about my experience with smallpox. I was chagrinned to say that we had eliminated smallpox from the United States and I'd never seen a case of smallpox and my Indian host said, "We will change that tomorrow morning." And he picked me up after breakfast, and we went to the Fever Hospital on King Arthur Road, and we went to the smallpox ward 00:23:00and we just walked down the ward, and he showed me one case of smallpox after another. We were not allowed on the ward until we had dipped our hands in a solution of potassium permanganate, which was our disinfectant, what was the equivalent of hand hygiene at the time. He showed me one patient after another including a newborn who had a pox right on the top of his head, and he showed me another patient, and he said very blandly, "He will be gone by this evening." And so I saw one patient of smallpox after another which reminds me that on one occasion as an EIS officer I was called to northern Rhode Island because a wool sorter working in a factory had anthrax and so I saw my first and only case of cutaneous anthrax, well-diagnosed, on its way to healing. All of that 00:24:00transformed itself into much later here in Nashville at a meeting of the Nashville Academy of Medicine. The local physicians talking about bioterrorism. Remember when that was very lively and the local director of the health department asked the question for a show of hands how many in the audience had ever seen a case of smallpox? There were a few of us. And then she asked how many had ever seen a case of anthrax. Only one hand went up.

TORGHELE: It was in Rhode Island.

SCHAFFNER: Yep. That was my case in Rhode Island. But I mean the EIS experience, those two years, has resonated throughout my entire career.

TORGHELE: So, you went to India, and it was not long after you went to India and saw those smallpox cases that smallpox was actually eradicated from there.

SCHAFFNER: Yeah, that's exactly correct. Actually, when I was an EIS officer, we promoted smallpox vaccination in our hospitals because that was standard back then. We wrote a little paper about the adverse experiences that some of the recipients had had, and then years later, 20 years later when we started to vaccinate for a period of time against smallpox, that paper was resurrected and became part of the discussion of the kinds of adverse reactions you might experience with smallpox vaccination. So once again, the EIS experience had resonances later on.

TORGHELE: So, you feel like you were well prepared to do the work you did.

SCHAFFNER: Oh, yeah, absolutely, and coming back to Nashville [Tennessee] and to my own medical community both in the city and throughout the state I was the 00:26:00person who had the closest link to the CDC on many projects and so when HIV [Human Immunodeficiency Virus] came upon the scene, I was often the conduit of the latest information that went out through the state about what we were learning about HIV infection. So once again, the link with the CDC became very important. It was important to patients and to providers here in my own local environment.

TORGHELE: So, you maximized the use of those connections throughout your career.

SCHAFFNER: Well, I've had many associations with the CDC and because I also had associations as a practicing infectious disease clinician and academician I was able to often communicate among my friends and bring them all together and I was able to just facilitate collaboration and that worked beneficially in many, many 00:27:00different ways and principally in an educational fashion.

TORGHELE: I know that after your EIS years you came to work at Vanderbilt [University], so could you talk about an EIS officer who was assigned in Tennessee at the Department of Health who had an assignment that you were able to help with? Can you talk about that?

SCHAFFNER: Well, when I came back to Vanderbilt, I immediately established a relationship with the state health department. That took a little work over time, but soon I was a guest in their house, and that relationship has continued warmly and closely to the present day. I became a co-supervisor of the EIS officers who were assigned to the Tennessee Department of Health, a source of great joy for me. One of the EIS officers, [Dr.] David [L.] Freeman, had great 00:28:00competence in Spanish and there was an outbreak of polio in Nicaragua, and so he was recruited as part of the epidemic aid team to go to Nicaragua, but he was given two assignments. He was not only to help with the epidemiology of polio in Nicaragua, but because he was an internist, he was going to be asked to help in the clinical care of patients with polio in Nicaragua, which he quickly shared with me, filled him with terror because he'd never seen a case of polio. So, I quickly arranged for a tutorial. Two persons at Vanderbilt helped him enormously. The first was Dr. David [T.] Karzon who was chair of our Department of Pediatrics, a pediatric infectious diseases eminence who, in his youth, had cared for many patients with polio. He graciously made an hour available. We went to his office and spontaneously he gave an eloquent one-hour disquisition 00:29:00on poliomyelitis and the diagnosis of the cases and how to care for them in all of its nuances. I remember one of the things he said, that if the patient needs the care of a tank respirator, the iron lung, you had to do a high tracheostomy because if the tracheostomy was too low, the way it's usually done, it interfered with the collar of the tank respirator. I mean it went down to those nuances, how to use the ports, how to care for patients to make sure they didn't get a urinary tract infection or pressure ulcers, even their mental aspects because after all you're confined in a tank respirator and you can get very claustrophobic. If you're in a polio ward, that can actually be contagious, other patients can get anxious if they hear that you're getting anxious. So, it 00:30:00was just wonderful and David was taking notes constantly, constantly. We said thanks to David, and then I took him (Dr. Freeman) by the hand, and I went to the basement because in the basement we still had some tank respirators and I introduced him to the former head nurse on our old no-longer-existing polio ward. She'd taken care of scores of patients because Vanderbilt had been a regional center for the care of patients with poliomyelitis in-tank respirators. It was part of our reputation which was waning because we didn't have any more polio, but we still had this extraordinarily skilled former head nurse whose name now escapes me. But anyway, she took him down, had dusted off that tank respirator, set it up, plugged it in, had it working, and from beginning to end she told David how to care for patients in a tank respirator. Once again, he 00:31:00took an awful lot of notes. She came to the end of her teaching, looked at him, and said, "So do you think you understand all that?" And he said, "Well, yes, of course, I've got it all written down here. I'll study it before I go down to Nicaragua." She said, "So you think you understand this?" And he said, "Yes." And then she drew herself up, made herself into a stern head nurse, and she said, "Well, one more thing." She reached over, opened up the tank respirator, looked at him and said, "Now get in." She made him get in, closed the tank respirator and turned it on. She said, "You have to feel what it's like to be in the tank respirator." And she'd even get into the nuances, "You're fighting the 00:32:00respirator because your rate of respiration is different (swish, swish) with the rate (swish, swish) of the tank respirator. Now you know what it's like when patients start to recover the function of their respiratory muscles and want to start breathing on their own--they'll fight the tank respirator because they're not in synch." And then she gave him hints about how you can give people a chance to be outside the tank respirator and help and nurse them off the tank respirator. It was just powerful. So, when David came back, he told me he had 00:33:00been eloquently prepared epidemiologically by the CDC and eloquently prepared by Dr. Karzon and this head nurse to really assist in the care of individual patients in Nicaragua. He thought it was a very successful and wonderful CDC that he was able to participate in this consultation for the benefit of the health of the people in Nicaragua. He was very pleased with that.

TORGHELE: What would be the circumstances where someone could be in a respirator or an iron lung and then come out of it? How would one know that a person was healed enough to come out?

SCHAFFNER: Well, the inflammation in the spinal cord can recede. You get all 00:34:00kinds of inflammation because there's increased pressure and the inflammation causes increased pressure within the central nervous system. You get compression of the spinal cord, so you have at the moment the damage to the anterior horn cells which also have the inflammation which causes more dysfunction initially. Then as the infection recedes, as you start to recover, the inflammation recedes, the intra-CSF [cerebrospinal fluid] pressure recedes and so then you get increased neuronal function once again and so some of the paralysis then will recede and you can recover function and you just have to constantly test for that and then help the patient. You don't want to take him off the respirator too soon because they'll have a respiratory crisis, but you have to let them gradually have more time out of the respirator to accommodate 00:35:00themselves and you just have to monitor them very, very carefully.

TORGHELE: Must've been a moment of triumph when they would come out of the iron lung--

SCHAFFNER: Oh, yeah, for sure. But then obviously there were some people who were confined to the respirator for essentially the rest of their life because they never recovered that function. Those anterior horn cells which sent motor signals to the muscles of respiration were destroyed, and so they could not recover function. My chief of medicine had a particular affection and close relationship with a patient who lived in rural southern Kentucky who he'd been taking care of at Vanderbilt and he would visit her occasionally in her home. She chose obviously to have her respirator at home. Her whole family was trained in the respirator. They had to have a generator in the home because periodically 00:36:00there would be thunderstorms and there would be power outages, and it had to switch immediately to the generator to keep that respirator going. You could do it mechanically, but you wouldn't want to do that for a very long period of time. So those people were in a very fragile circumstance but obviously wanted to be close to their homes, close to their families, in an environment that was familiar, and the whole family had to change its whole way of life. They had to focus on that respirator and all the care that it required to keep that patient not only alive but healthy with good skin tone, for example, avoiding urinary tract infections, avoiding complicating pneumonias and the like. It took an awful lot of care. I mean you had to have a whole family be basically trained as intensive care nurses.

TORGHELE: This was before the days of Medicaid and Medicare. How were they able 00:37:00to afford an iron lung in the home?

SCHAFFNER: I think probably the National March of Dimes contributed a lot of support to patients who were iron lung tank respirator-dependent. I would imagine that's the case. I don't have firsthand knowledge of that, but I would anticipate that's the way it went.

TORGHELE: So, March of Dimes not only contributed to the development of the vaccines and the research but they helped patients afterward.

SCHAFFNER: Oh, the March of Dimes contributed a great deal of support to the care of patients with poliomyelitis. Physical therapy, the use of crutches, tank respirators were only a part of that, yes. And obviously, they funded the research that resulted in the polio vaccines, both the injectable vaccine and 00:38:00the oral polio vaccines. They funded, we funded. I mean I remember, as I said, putting the dimes in those things. It was a remarkable way to involve essentially the entire population as research grantors. We contributed this in our own small way constantly. Even we children were told to help other children by saving our dimes and giving our dimes, which we had gotten in our allowance or maybe as a present or for some work we had done we'd gotten a little money. Let's make our contributions. Not just my mother's dimes but our own, and it was a remarkable way we were all involved in this public health enterprise all the way from research, all the way through to clinical care. It was a remarkably 00:39:00American thing to do.

TORGHELE: The March of Dimes was all privately funded.

SCHAFFNER: Yes.

TORGHELE: No government money.

SCHAFFNER: That's correct.

TORGHELE: It's unprecedented. So, talking about the vaccines, can you talk about any introduction you may have had to Dr. [Jonas E.] Salk or [Dr.] Albert [B.] Sabin or Hilary Koprowski, the developers of the vaccines.

SCHAFFNER: Well, all those eminences, of course, were well known including Dr. [Maurice R.] Hilleman who was involved in other vaccines and I was occasionally at a scientific meeting where those eminences with their auras were present. I met any number of them personally but fleetingly. I mean they wouldn't recognize me from a tomato if they were in the same room because I was just kind of this novice little person and they were so eminent. But I do remember the occasion at the academic Atlantic City meetings of yesteryear making some sort of infectious 00:40:00disease presentation. I don't remember what the topic was, but I was a fellow making one of my very first presentations before a scientific audience and breaking out into a sweat when I saw Dr. Sabin approach the microphone to ask a question and he was a notorious fierce questioner. And he asked me, as I recall, I can't remember what it was--a tough question. But I acquitted myself well because he didn't give me a second bite. He nodded his head and went back to his seat after I answered his question. I'm breaking out in a sweat just thinking about it.

TORGHELE: What a relief that must have been.

SCHAFFNER: Well, it was exciting to have him ask and have an interest in what I was presenting. It was even more exciting that he sat down again and didn't ask me a second question.

TORGHELE: In talking more about vaccines, there is a committee called the 00:41:00Advisory Committee on Immunization Practices. Can you talk a little bit about that and how that came to be and your involvement in it?

SCHAFFNER: Well, my involvement with the ACIP has been extensive over the years. I don't have so much gray hair that I was present at its creation, but I was pleased--I mean I was awed--when I got an invitation to join the ACIP as a member in 1982. So I had one tour of duty as a full voting member of the ACIP, and since that time I've been what's called a liaison representative, accredited there by a scholarly or professional society. We sit at the literal outer table, we participate fully in the discussions, we can be members of the working groups, their subcommittees, but we don't vote. I must say I'm a little 00:42:00chagrined to admit that once Dr. Stanley [A.] Plotkin a few meetings ago announced that he was no longer attending, I'm afraid I'm now the ranking member, the person in the room who's had the longest continuing association with the ACIP. That's very humbling because you think of yourself as younger, but the calendar tells you differently. So, I've been associated with the ACIP for a long time.

TORGHELE: You have an interesting experience related to ACIP with a friend of yours, too, I understand.

SCHAFFNER: Karen, you ask me about my perhaps most substantial experience with polio related to its public health aspects. This was back in the day, I don't 00:43:00know the exact dates, when I was no longer a member but a liaison representative sitting in the outer table. I always sat next to my dear friend, Dr. Pierce Gardner who was there on behalf of the American College of Physicians, the Internal Medicine Organization. I was there, I think, on behalf at the time, and still am, of the National Foundation for Infectious Diseases. We always sat together and we internists were like the kids in the third grade that the teacher tried to keep separate because we were "ra-ra-ra-ra" making comments about what was going on. Often laudatory in agreement but then on occasion say, oh, why did they do--you know, being a little grumpy about why certain decisions or discussions were going on. Well, in that context I remember that Dr. Roland [W.] Sutter, a CDC personage who has worked with the World Health Organization for ears and years and an international expert on poliomyelitis, was giving a 00:44:00review of polio in the United States at the podium -- of course, one of the things he dwelt on was the fact that we experience several cases each year, somewhere between six or eight or ten, of vaccine-associated poliomyelitis. We were using the oral polio vaccine. It went down into your intestinal tract, mutated, and developed, reverted to wild-type polio, could escape the intestinal tract, and actually cause polio itself. The vaccine did that. And sometimes you would spread the vaccine virus to someone else and they got vaccine-associated poliomyelitis. About six to eight of those cases, maybe ten occasionally per year. That's an interesting theoretical concept when you sit back and think about it, but my daughter actually babysat for the daughter of a medical 00:45:00resident and his wife. She got polio vaccine, that is the daughter, and she developed vaccine-associated poliomyelitis. It's one thing to think about that--it's another to have it so close. So, it has real profound meaning. Here we were trying to protect these children against polio, but we actually created polio in the United States six to eight to ten times each year, and that was a matter of great distress to everyone. So, I think it was I who first in my "ra-ra-ra-ra" turned to Pierce and said, "Why don't we think about--" "Yeah," he said, "I'm thinking about the same thing, why don't we switch to IPV [inactivated polio vaccine], then we would eliminate this problem." Yeah, there are a lot of problems with IPV, it is injectable, you have to give more doses, 00:46:00you know, it's probably more expensive but "ra-ra-ra-ra". And so, he said to me, "Raise your hand and make that comment." And I said, "You know, on the previous topic I raised my hand, and I made kind of a critical comment-- it's your turn." So, Pierce raised his hand, and he raised that whole question, "Why don't we consider switching to IPV?" The room was silent. That was not only outside the box, it was outside the universe to think about that. "Ra-ra-ra-ra" and they went beyond that pretty quickly. Didn't think about that very seriously. Immediately after on break we were approached by our mutual good friend, Dr. Alan [R.] Hinman, a vaccine authority person with whom we were more than genially acquainted. We were really buddies with Alan, and he'd been involved with polio around the world, and he gave us what-for because I mean 00:47:00"ra-ra-ra-ra" you shouldn't have brought that up "arr-arr-arr", it'll never work. And he gave us 33 reasons why it was a bad idea. Okay, thought we'd just talk about it. It was not the next ACIP meeting, but maybe two meetings later or something like that, my memory here is a little vague. Well, CDC was going to undertake a study to look at this question about what would actually switching to IPV entail. Not an easy thing. Lots of problems. But maybe it is something that ought to be done. To make a very long story short, of course, we decided to make that switch, and that had ramifications for global polio eradication. So maybe my memory is not right, but I think if my friend Pierce Gardner were here today, he'd say, "Well, we weren't the flame, but maybe we were just a little 00:48:00spark that got all that started." So, we don't take credit for that, but that's kind of our memory of it.

TORGHELE: So, the rabble-rousers had something constructive that came out of it.

SCHAFFNER: Right. It might even be true.

TORGHELE: And your experiences with ACIP, there were probably meetings that stood out in your mind as having more significance than others like that one. Are there other examples of decisions that were made as a result of people who attended the meeting or brought things up that were different or unique?

SCHAFFNER: The ACIP has been such an extraordinarily rewarding experience. So many people devote so much time and energy at really little or no compensation 00:49:00to try to do the best for the population, and there are always issues that come up. The times where we debated whether we should, once again, use smallpox vaccine. The whole experience over several meetings, it must've taken a couple of years for us to assess whether or not we wished to switch from oral polio vaccine to injectable polio vaccine. The introduction just recently, of an extraordinarily effective vaccine against shingles in older people who have diminished immune systems but with a new adjuvant, we seem to have addressed and solved that problem to provide new protection. I mean it's just one thing after another and then particularly for pediatric immunizations the fact that the ACIP members, the full members, adjourned and then reconvened themselves as the Advisory Committee to the Vaccines for Children's Program where they vote on the 00:50:00same issues the same way again. Once they make that vote, because the Vaccines for Children's Program is an entitlement program, the Congress must find the money to support it. So, the Congress has given to an external group of experts not only authorization but appropriations authority. I don't know of any other external groups where the Congress has said, "You all decide what to do, and you tell us that we must pay for it." I mean that's just beyond extraordinary. So, the whole experience of being part of the ACIP has been among really the most rewarding things that I've done professionally in my lifetime. It's just been 00:51:00wonderfully satisfying, and it's transparent. You can watch what happens on the web in real-time. It is the epitome of open policy-making where everyone contributes. People can attend, the general public can attend. People have come in who are survivors of meningococcal disease, and they give their public comment. Those people have influenced the decisions that are made by the full members, and there are many other people who offer public testimony and have that opportunity at each and every meeting. It's the epitome of open democratic policy-making. It's a treasure. In fact, there have been times when I've said 00:52:00I've looked at the CDC--it's grown enormously, and I think of all the people working there on all aspects of public health. But then I ask the rhetorical question of friends, "What's the single activity at the CDC, the single program, that has the most direct impact on the health of Americans and beyond?" The operative word is "direct." Beauty is in the eye of the beholder, but I really think it's the ACIP because once they make recommendations, it becomes the standard of practice and it's translated into action almost instantly. It's powerful, and it's all for the good.

TORGHELE: And these are all subject matter experts.

SCHAFFNER: They are generalists and subject matter experts that come together. It brings together vaccinologists, pediatricians, public health people. There has to be a representative of the general public. A non-professional person now who's part of the full membership of the ACIP and those people bring a distinctive perspective to those discussions.

TORGHELE: How are they chosen?

SCHAFFNER: They're chosen by nomination by a variety of groups and they can self-nominate.

TORGHELE: So, someone who has had an experience maybe with a type of vaccine would be interested?

SCHAFFNER: The public representative member usually has had in some form or other an experience with vaccines, sometimes in a sustained way, sometimes more episodic and I think personal.

TORGHELE: When you have the meetings, you said the public can come, so anyone can come to these meetings who has an interest in vaccines. Is that right?

SCHAFFNER: The meetings are open to the public. You have to register. You can't just walk in the door, you have to register, but you can sit at the meetings. If you sign up for public comment, there are several moments during the meeting when you will be called upon to come to the microphone, and you're given, I believe it is, three minutes to make your public comment concerning the issue that's currently being discussed.

TORGHELE: I understand that you have had some anti-vaccination people who have come to the meetings and had public comments.

SCHAFFNER: People who are skeptical of vaccines and I get the sense some people who are genuinely anti-vaccines have come and they are part of the richness of 00:55:00the discussion. They often provide very vivid comments. They're made very, very passionately.

TORGHELE: Can you remember some episodes that stand out in your mind related to that sort of thing?

SCHAFFNER: Well, the single episode--you listen to these people very, very carefully just as you listen to vaccine supporters. But the thing that I remember most vividly in this regard is that we once went to a meeting and all of a sudden there was security there, armed security, and we'd never seen that at an ACIP meeting before. When we asked about that, it's because my colleague, Dr. Paul [A.] Offit, who speaks out clearly about vaccines all the time, had threatened--his life had been threatened. And so, at these meetings, there was now security to help secure Paul. I remember also walking across the street from 00:56:00the hotel to the CDC. Outside the CDC grounds, there were people who were (excuse me) protesting vaccines and we were walking with Paul, so we all surrounded him as we walked past those individuals going to the meeting.

TORGHELE: You have a unique role as an academician and a clinician. So, I remember a story you were talking about of a woman who was in an iron lung and she was a young woman, and she and her husband wanted a baby. Can you talk a little bit more about her?

SCHAFFNER: Yes. This must've been when I was either a senior resident or a fellow because I spent a lot of time at her bedside, the tank side, caring for 00:57:00her illness. She had been admitted to the medical service for some infectious illness, perhaps a urinary tract infection or it might've been a respiratory infection, so we were caring for her. She was pregnant at the time. She lived at home in an iron lung, could stay out of the iron lung for a period of time. She and her husband conceived a child that was, I thought, the epitome of closeness, love, optimism, an attempt at normalcy, to try to be a whole complete family in the sense that they had both thought of family before, being married, having children, a progeny that would carry on their genetic legacy into the next generation. I was deeply touched by that and just profoundly impressed at how the relationship between those two people transcended the lady's disability. 00:58:00They chose not to focus on the disability but on the future and the bond between them. I'm moved thinking about it. She had a normal baby later I heard. Didn't know the details when she came in for obstetrical care. She didn't have an infection apparently so we weren't called in at the time, but I heard that she had a normal baby.

TORGHELE: It was a baby girl, right?

SCHAFFNER: I don't remember the sex of the baby, but she had a baby.

TORGHELE: That's a beautiful story. So, the oral polio vaccine and the inactivated polio vaccine issues stimulated lots of discussions between the 00:59:00clinicians and epidemiologists and some strong feelings at times were expressed. So, can you remember some of the points that each side made when the decision was made to switch to IPV from OPV?

SCHAFFNER: Oh, goodness. I don't think this is the time for us to create a mental table of the advantages and disadvantages of IPV and OPV but certainly the ease of administration and the fact that this was a--you know, the injectable vaccine you have to inject it, so it's a needle and syringe. So, we were adding to the pin-cushion effect that we have with babies today, and everybody liked the ease of the administration of the oral polio vaccine. The oral polio vaccine was a live vaccine. It replicated in the intestinal tract and could be passed on to others, so if a neighbor child didn't get vaccinated, they 01:00:00might get vaccinated because the vaccinated child passed the OPV virus on to the neighbor child and so the neighbor child would get vaccinated just through close contact. So, you had kind of horizontal transmission of the vaccine virus, for example. So, there were lots of differences between the two, and obviously, we had established ways of delivering the vaccine, and there was a great deal of concern that adding this injectable vaccine would impede the vaccination program because moms wouldn't accept it for their children, and could this be an effective transition. I remember one occasion doing a survey (laugh). I call it a survey. That is, I asked my wife. My wife is a wonderful person. She's not a medical professional, and on occasion, I have presented her with a question, and 01:01:00I try to present it in as objective a fashion as possible, and I was fascinated to find out what this mother would say about which vaccine ought to be used. So, I presented all the information in a very objective fashion to her and she looked at me at breakfast and said, "You mean with this vaccine there's a chance between one and three million"--realize how infrequent that is--"but there's a chance that my child could get paralytic disease and this one not?" She said, "That's easy. That!" And it was just like that. No discussion. So, I actually brought that back to friends and not formally to the ACIP but certainly over a cup of coffee at the break. They all chuckled, but they said, "Hmm, look at that". Turned out that's the way it was. My wife was right about that and many 01:02:00other things.

TORGHELE: It's nice that you admit that.

SCHAFFNER: Oh, yes, you better admit it.

TORGHELE: So, talking about the chance of paralysis with the oral polio vaccine, there were some legal issues with that, and there was a commission, the National Vaccine Injury Compensation Program, and were people who got vaccine-associated paralytic polio compensated by that program when they got it?

SCHAFFNER: Well, before the program existed and that National Vaccine Compensation Program is funded through a little surcharge that's on every dose of vaccine that's given to children. All that money, those pennies literally, I think it is twenty-five cents a dose, goes into a fund in Washington that's secured for the compensation of people who had bona fide vaccine-related 01:03:00injuries, and they can apply to that program and there's a structure and a process that they have to go through in order to get the compensation. The compensation helps them financially often to care for children and others who have had vaccine injuries. It can't compensate them completely, of course, but it's a way to do that. Before that program existed, there were individual lawsuits against vaccine manufacturers for creating defective products even though the product limitations--that is the occasional serious adverse effect of the vaccine, was well known and well communicated. Nonetheless, there were big lawsuits that were settled or decided in favor of the plaintiffs. The people who made the claim who had had the injuries and that threatened actually our vaccine industry because they couldn't anticipate how much their risk was, and we 01:04:00actually had vaccine manufacturers that decided to go out of business because of the uncertainty of this financial hazard. So that stabilized the entire vaccine research, manufacture, and delivery programs that we had and so the Vaccine Injury Compensation Program has been an enormous public health and personal asset.

TORGHELE: So, the pharmaceutical companies could continue to manufacture vaccines knowing that there was a backup program to help them if there was a problem.

SCHAFFNER: Yes. Of course, the vaccine manufacturers had to comply with all the safety and manufacturing restrictions and requirements of the Food and Drug Administration, else they couldn't get licensed. So they complied with good manufacturing practices but nonetheless since there's no such thing as a 01:05:00perfectly safe vaccine or for that matter a perfectly safe drug, there are always adverse events, some of them rare but serious, that will affect individuals and those individuals now have recourse. They can raise their hand and go through a process and ask for some financial compensation and that stabilized things and I think it's socially fair and appropriate.

TORGHELE: It's a service to all of us and to public health.

SCHAFFNER: Yes, absolutely.

TORGHELE: My other question is as an academician, what do you see as your role related to vaccine-preventable diseases like polio, as far as educating the public and parents who are wanting to know and get the latest information?

SCHAFFNER: Well, aside from the fact that I'm still engaged with research and 01:06:00colleagues in the Emerging Infections Program dealing with vaccine-preventable diseases, their assessment, and actually evaluating the impact of vaccines. My general role is as an educator, of course, we're in academics, and we educate our students, and I regard the general population as students because the general population really acquires new information not by going to schools or taking courses. Of course, some of them do, but most of what they learn about changes in infectious diseases come through the general media and so I see the general media as an educational device. But, you know, it is interesting Karen, our students are people and they come to us with all the background of people. There are now some studies to indicate that medical students, hear me now, medical students come with vaccine skepticism because that's what they've 01:07:00learned. They've gone to the internet with that, and so we have to educate them about that. We have to educate them about poliomyelitis and what is it? When I tell them to use another virus as an example, that before we had measles vaccine in the United States--with a much smaller population than we have now--had between 400 and 500 deaths of children due to measles and complications, their jaws drop. I mean this is a stunning notion. I have to say it twice in order to convince them. And then occasionally, I've had more intimate discussions with members of the general population, not just through the media. This was a few years ago. I was asked to address a group of parents who were curious about vaccines. They weren't anti, but they were full of questions, vaccine skeptics 01:08:00we might say, and most of them were moms, but there were some dads there. Must've been about 20, 25 people in the room. I decided I wasn't going to try to convince them of anything, but I was just gonna talk about stuff. And of course, in order to talk about the vaccines, I had to talk about the diseases. I talked about measles, and then I began talking about polio and one of the ladies in the audience got a very querulous look on her face and I said, "Let's hold on for a moment, Ms. Jones, you seem to have a question, how can I help you and then we can all get on the same page." Remember I was talking about polio. And she looked at me and said--this is a quote--"Why are you suddenly talking about shirts?" Polo. Polio. College-educated, computer savvy, had been out in the business world. She had never heard of polio. I had to go over it again. I was 01:09:00happy to do that. Brought her with us. She's a bit of an extreme example but maybe not so extreme. She illustrates what the problem is. I'm going to get on a hobby horse for a moment. We did a (ha) survey. We asked around about the health curriculum of middle schools and high schools-- what do they learn about vaccine-preventable diseases and what vaccines are and how they work. It's very catch as catch can. Mostly can't. It's uncertain, sporadic. Almost nothing is talked about those diseases and what they learn about vaccines varies a lot. Or course, they have so many other things to teach young people about regarding health-- obesity, opioids, you know, all that kind of stuff. But we really need 01:10:00to educate. We need to change the curriculum of middle schoolers and high schoolers. Those kids are gonna become parents and if they don't know what polio is or measles or diphtheria, how are they going to value the vaccines. So, we need to give them that basis because now when they come to parenthood, they come with an educational gap, a great vacuum. Is it a surprise that so many parents are asking their pediatricians for a primer on the diseases? Why do I have to have--what are these diseases? And pediatricians and their entire staff are trying to give remedial education to all these parents. The answer here is not a medical or traditional public health answer. It's an educational answer. We have 01:11:00to move into the educational environment and create curriculum materials, videos, we need to get into those textbooks and make sure that the textbooks have the appropriate chapters. We need to educate the teachers because that would be, from my point of view, one of the responses to the international vaccine skepticism movement, education, education, education.

TORGHELE: And medical students, too.

SCHAFFNER: Everyone. Medical students, nursing students, all of us in the healthcare professions. You'd be surprised how much lack of information, skepticism is. You know, when there's no disease, you focus on the side effects of the vaccines-- because you don't know the disease, you don't value it. It's 01:12:00been two now, on to the third generation. It used to go down through the maternal line, all of that culture about the diseases and what the mom and the grandmother saw. The grandmother didn't see any measles, the mom didn't see any measles so why should they value--what's that? Why value the vaccine? I mean we need to get that information back into the educational system. That's at least a start. There's no panacea here. The better we are at vaccinating, the more struggle we will have in the future vaccinating.

TORGHELE: What have you found to be the most effective way of educating people?

SCHAFFNER: I educate people the only way I know-how. Calmly with information. I 01:13:00always start with the diseases. I like to talk about individual cases to try to make it vivid, to make it real so that they can personalize it, and then I talk about prevention and what a vaccine is and how it fools the immune system to think that it's the real disease so when they encounter the real virus, people will be protected. Just that kind of general stuff. I also try to listen very carefully to the concerns and respond to them, but I have my underlying message, my themes that I come back to. Disease bad. Vaccines good.

TORGHELE: I've heard you deal with some difficult people. I've heard you talk with an anti-vaxxer and you were so respectful, and you listened, and that seemed to calm that person down, and at the same time you were giving some valid 01:14:00information back.

SCHAFFNER: Well, you know, I've had any number of opportunities. Some like Paul have had many more than I have because he's so much more vivid and out there even more than am I. But you do get interesting interactions. I'm in memory of one occasion where I was a member of the National Vaccine Advisory Committee when Ms. Barbara Lowe-Fischer, a staunch--I will call her an anti-vaccine person--was on the committee. A very stern person. And I made my best effort to develop a relationship with her just to say hello, to sit next to her, engage her in a little chitchat during the breaks and stuff like that. Over time as one meeting went into another, we developed at least a genial hello, and when we saw 01:15:00each other at the next meeting, we greeted each other by our first names and she also gave me just a little smile. Stern visage. At one point, I think it must've been during a break, I had the temerity to say, "Barbara, can I ask you a question? I'm just interested, I've read so much of what you've written. Of course, I listen very carefully to what you say, and I've heard what you've said on television"--we'd been on television together--"Tell me, have you ever said anything good about vaccines? I know you always begin your statements by saying, 'I'm not anti-vaccines but'--and then the jar is 95% empty in effect. But "Have you ever acknowledged that vaccines have eradicated smallpox from the world?" (Back then when we were on essentially eliminated, we hadn't yet declared elimination of measles from the United States but essentially so), "That there's 01:16:00no more diphtheria in this country because we vaccinate children against diphtheria. I could go on and on. Have you ever acknowledged that?" She just looked at me and remained silent, and we went on to something else.

TORGHELE: So, she couldn't say--

SCHAFFNER: Couldn't, wouldn't. I was never close enough to Ms. Fischer to get into her mind, but she clearly had, I think, it's pop psychology, excuse me, just self-identified, her whole identity was by then her whole vision of herself, her mission, her role in life was as an anti-vaccine spokesperson.

TORGHELE: Can you remind us of her story, how she got involved in the 01:17:00anti-vaccine movement?

SCHAFFNER: You'll forgive me because I think I remember it, but here I am on tape. I wouldn't want to discuss that unless I brushed up my memory about that, but I think I recall how it happened-- through personal experience with one of the vaccines, a child of hers who had what was thought to be a substantial adverse reaction to a vaccine.

TORGHELE: Okay. What can you tell us about the elimination of polio now from the planet? It started with the Western hemisphere here, and lots of people were involved in that, and now we're close to the extinction. Do you think it's going to happen?

SCHAFFNER: We get closer all the time and then it's two steps forward and maybe a half step back. But we're down to just Afghanistan, Pakistan, Nigeria, 01:18:00turbulence, ignorance, conflict, misinformation. It's not for want of trying, but we're close, and I'm an optimist. My jar is three-quarters full and maybe even more full than that. So, I hope we persist, and I hope not a single vaccinator has to give their life further in this cause because so many have been murdered, largely women going door to door to try to prevent a paralytic viral infection in their communities, children, who have been killed. When our 01:19:00students hear about that, I have to tell them maybe once again, twice, that this has happened many times. That gets to their hearts as well as their minds.

TORGHELE: It's good to be reminded of those heroines.

SCHAFFNER: Oh, yeah. We're all together, we're all healthcare workers, we're all trying to do that. But talk about front line hazard and commitment-- commitment to their own communities, commitment to a better healthier next generation. It's awesome.

TORGHELE: I know that we're getting close to our time limit and I wanted to be sure that you had time to cover anything that you didn't have a chance to talk about, if there are any final thoughts that you had. And I have another question if--.

SCHAFFNER: I think you've wrung most of my thoughts out of me, Karen, and I'm braced, as with Dr. Sabin, for your next question, your zinger.

TORGHELE: I'll be kinder. I was thinking--I was noticing that your children's hospital is having some additions and some changes to it and I wondered if you could talk about that a little bit.

SCHAFFNER: I know what you're referring to because we had a previous conversation. This is a way of educating that I have used from time to time. A few years ago--yes, we are expanding our children's hospital, but when it was first opened, we were so proud of it. It was a major new regional addition to child health to provide medical care to seriously ill children in the entire Mid Central South, as we call it, and we were so proud of it. Not only was it 01:21:00physically striking, not only did we have a wonderful faculty and staff, they've cared for my grandchildren. They are splendid. Not only all of that but as one of my friends said, we put the latest whiz-bang medicine in there for the benefit of children. So, I would ask people, you know, there was an area in which Vanderbilt was preeminent in our entire region. We had faculty who were national authorities in this aspect of pediatric medical care, but we didn't build that expertise. We didn't devote space in our new spanking brand-new fancy children's hospital. Why didn't we do that and what was it we decided we weren't 01:22:00going to build in our children's hospital? And they all look at you puzzled, and I said, "We didn't build a polio ward. We were a regional center for the care of children who were paralyzed seriously with polio. We didn't put in a polio ward, because there's no more polio."

TORGHELE: I think that's a wonderful way to end this interview. I've enjoyed it so much, and I can see why you're a great educator. Your stories illustrate perfectly the points that we need to be reminded of. I want to thank you so much.

SCHAFFNER: Karen, it's been a great pleasure. You can see I get emotional about 01:23:00this. It is in service to others. That's what public health is. We're all together, we all try to improve the quality of life for all of us, and we're all optimistically devoted to making the next generation even healthier than ours, and we do it with equity and distribution to all. One of the things we haven't mentioned is one of the incredible benefits of our infant childhood and adolescent immunization program. It's almost never mentioned. It eliminates disparities by income. We always talk about disparities by race, urban, rural. These benefits reach all of our children no matter their circumstance.

TORGHELE: Thank you so much. That's a great message.

SCHAFFNER: My pleasure.

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