June 1997
Immunizations was not the path Walter A. Orenstein, MD, had intended to take when he graduated from Albert Einstein College of Medicine in 1972. It was not a consideration when he finished his pediatric internship and residency at the University of California, San Francisco, in 1974.
"I thought I wanted to go into pediatric nephrology," said the director of the National Immunization Program at the Centers for Disease Control and Prevention, who is planning a sabbatical this summer.
Thanks to the Vietnam War, doctors of draftable age were obligated to serve their country, and Orenstein, like so many of his peers, had been considering his options throughout college and medical school.
"My cousin had been an epidemic intelligence service officer in 1956, so I asked him what I should do, and he mentioned that you get to travel [in the public health service]," Orenstein said.
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Travel sounded like a wonderful opportunity. "I spent most of my life in the Bronx. I went to City College of New York. I went to medical school in the Bronx. Even though I moved out of the house, it was about two miles from my parent's home. By the time I finished medical school, I was ready to travel, so I put in for the epidemic intelligence service."
The government started winding down the draft, and the Paris Peace Accord was signed in 1973, effectively ending America's involvement in the war. Orenstein no longer had to decide how to serve his country. However, an "anti-service" sentiment had developed in the country, and the public health service checked to see if he was still interested. "The doctor's draft had ended by that time. I got a call on the wards, 'Do I want to do this?' and I said okay."
Even after joining the public health service, his goal was not to devote his life to immunizations. He requested several available slots, mostly in the West. "That [immunizations] was my last choice. I got that, and I remember being real disappointed."
His disappointment did not last for long. "There was a smallpox eradication program, and they needed lots of epidemiologists. Bill Feighy, who later became the director of the CDC, gave a speech that was so inspiring, I think I would have walked over a cliff for him. I put in for smallpox. I wasn't sure what I was getting into. I was excited because I got to go around the world," he said.
The trip became more than just a few snapshots and memories. "It was almost a religious experience," Orenstein said. "I saw a disease that was disfiguring, that had about a 15% mortality rate be eradicated before my very eyes."
He was stationed in India's largest populated state near Nepal. "It was roughly the size of California but there were many more people. In 1974, they had more than 30,000 cases of smallpox and over 5,000 deaths. I worked there between December 1974 and April 1975. I had the last case of smallpox in that state. It was a 7-month old girl who really died needlessly, unfortunately."
The strategy to eradicate smallpox was called search and containment — find the cases and vaccinate around them. "Smallpox is not highly contagious. You did not have to vaccinate the whole population, you just had to vaccinate around the case to prevent spread. You might vaccinate that whole village or you might vaccinate around that village within a five-mile area. You did not need to vaccinate the entire population."
His last case was tragic because the child was not vaccinated even though there had been a case in the household a month before. "We were only notified when this second case occurred. That case, I still remember. The onset was March 8, we heard about it on March 12, and the child died on March 16. This was the last case of smallpox in that state."
Public health officials were paying a 100-rupee reward for each case that was reported. "We would get chickenpox cases, we would get everything reported to us, we could not see any smallpox despite that a year earlier there were thousands and thousands of cases. And so, that had a dramatic impact for me to show what immunizations could do. Eradication is the biggest gift we could do — sort of a gift for all generations.
"I was smitten with infectious diseases and public health and so, pediatric nephrology was never really a consideration," Orenstein said.
In 1977, Orenstein left the CDC for three years to make sure he did not want to go into clinical medicine. He finished his pediatric training, spending two years at UCSF, an infectious disease fellowship at Children's Hospital in Los Angeles and a two-year pediatric infectious disease fellowship at University of Southern California Medical Center. "Then I came back to the CDC, and I've been here since 1980," he said.
Anyone who is involved in the field of vaccines knows Walter Orenstein; if there is a meeting on vaccines he's there. Now, Orenstein will be vacating his position for six months. He said it would be nice to have six months where he doesn't have to catch a plane.
"One of the nice things about this sabbatical is that I hope to get more time with the family. I have two kids, a daughter 14, and my son is 11 years old. They are really great kids. I'm looking forward to having time with my wife."
The assignment, to co-edit a textbook on vaccines with Stanley Plotkin, MD, and Edward Mortimer, MD, is similar to a sabbatical. "It's technically a detail. I will remain a member of the commission corps. I want to reacquaint myself to some of the technical issues of immunization because so much of what I do at this point is administrative and policy. This gives me the opportunity to go back to my roots and to deal with some of the technical, clinical and science issues that I missed all these years being at a higher policy level."
The book will feature new chapters on immunology, vaccination and general immunization practices. There will be chapters on public health-related is sues as well as chapters on immunizations in Europe and the developing world. And there will be separate chapters on safety monitoring, travel vaccines, vaccination of health care workers.
Orenstein is taking a break at a good time — U.S. immunization levels are higher than they have ever been, and outbreaks of vaccine-preventable diseases are relatively low. That success, however, has become a double-edged sword.
"The problem we face is short-term memory," he said. "The fact is our success with immunization and the major reduction we are seeing with virtually all of the diseases except pertussis makes people think more of the safety issues. The immediate benefit of vaccination is not readily apparent because disease is not present — we are not seeing epidemics.
"I think our challenge is greater because we don't want another epidemic to re-invigorate our immunization effort. We want to keep things going so that we never again have another epidemic of measles. We received so much publicity during the late '80s measles epidemic I recall very little of in the way of [media reports on] safety concerns because people saw a real problem with lack of vaccination. Kids were being hospitalized; adults were being hospitalized. People were dying of a vaccine-preventable disease, so the news stories were focused on the epidemic. Hence, we got a lot of publicity. I think people around the country were incensed by what was in a sense a needless tragedy.
"Part of the high immunization coverage we are seeing today is really a residue of all the publicity. As time goes on, that epidemic is going to fade into memory and then, it will be harder to convince people that there is a real benefit to vaccination."
Orenstein said that pediatricians have a vital role in promoting vaccines. "My personal belief — and I don't have any data for this — is that we didn't have these drops in immunization coverage because people still believe in their pediatricians, as opposed to other countries where pediatricians don't play such an active role in primary care. I think the pediatric community has helped in keeping the immunization message up and our immunization coverage levels up."
The lessons he has learned in his more than 20 years in public health are being brought to bear on the current campaign to eliminate polio, he said. "Now, I'm heavily involved in the polio eradication. Last December, I went back to India almost 22 years to the day that I had first come to India, in a trip that really changed my life," he said.
While there, he visited the family of his last smallpox case. "We found the father and family. They were still living in the same market area, very poor housing at the time. What was really touching — I did not realize I would meet him — I had pictures of my family and he asked to keep a picture of my son. My son's picture is hanging in Aligar. My son has lived, and his daughter has died.
"It came full circle. That is how I came back to the CDC and what immunization has meant to me over the years. This preventive power — when you see a patient as a clinician, it is very rewarding in terms of what you can do for that person. But what you can do in the public health program in immunization is do so much for thousands, and certainly for eradication, millions more."
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