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Facial recognition technology, history and the meanings of the face

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Facial recognition technology, history and the meanings of the face

The Author

Fay Bound Alberti

Fay alberti

This blog by Fay Bound Alberti was originally published on 17 February 2020 by Foundation for Science and Technology.

Facial recognition is increasingly commonplace, yet controversial. A technology capable of identifying or verifying an individual from a digital image or video frame it has an array of public and private uses – from smartphones to banks, airports, shopping centres and city streets. Live facial recognition will be used by the Metropolitan Police from 2020, having been trialled since 2016. And facial recognition is big business. One study published in June 2019 estimated that by 2024 the global market would generate $7 billion of revenue.

The proliferation and spread of facial recognition systems has its critics. In 2019, the House of Commons Science and Technology Committee called for a moratorium on their use in the UK until a legislative framework is introduced. The concerns raised were ethical and philosophical as much as practical.

This is the context in which a ‘Facial Recognition and Biometrics – Technology and Ethics’ discussion was convened by the Foundation for Science and Technology at the Royal Society on 29 January 2020. Discussants included the Baroness Kidron, OBE, Carly Kind, Director of the Ada Lovelace Institute, James Dipple-Johnstone, Information Commissioner’s Office, Professor Carsten Maple, Professor of Cyber Systems Engineering at the University of Warwick, and Matthew Ryder QC, Matrix Chambers. Their presentations are referred to below, and available here.

Like any technology, facial recognition has advantages and disadvantages. Speedy and relatively easy to deploy, it has uses in law enforcement, health, marketing and retail. But each of these areas has distinct interests and motivations, and these are reflected in public attitudes. There is greater acceptance of facial recognition to reduce crime than when it is used to pursue profit, as discussed by Carly and Matthew.

This tension between private and public interest is but one aspect of a complex global landscape, in which the meanings and legitimacy of the state come into play. We can see this at work in China, one of the global regions with fastest growth in the sector. China deploys an extensive video surveillance network with 600 million+ cameras. This is apparently part of its drive towards a ‘social credit’ system that assesses the value of citizens, a plot twist reminiscent of the movie ‘Rated’ (2016), in which every adult has a visible ‘star’ rating.

This intersection between fact and fiction is relevant in other ways. Despite considerable economic and political investment in facial recognition systems, their results are variable. Compared to other biometric data – fingerprint, iris, palm vein and voice authentication – facial recognition has one of the highest false acceptance and rejection rates. It is also skewed by ethnicity and gender. A study by the US National Institute of Standards and Technology found that algorithms sold in the market misidentified members of some groups – especially women and people of colour –100 times more frequently than others.

It is unsurprising that technology betrays the same forms of bias that exist in society. As Carsten identified, we need to understand facial recognition, as other forms of biometrics, not in isolation but as part of complex systems influenced by other factors. The challenge for regulators is not only the reliability of facial recognition, but also the speed of change. It is a difficult task for those tasked with regulating, like James, who has urged greater collaboration between policy-makers, innovators, the public and the legislators.

From a historical perspective, these issues are not new. There is often a time lag between the speed of research innovation and the pace of ethical understandings or regulatory and policy frameworks. It is easy for perceived positive outcomes (e.g. public protection) to be framed emotively in the media while drowning out negative outcomes (e.g. the enforcement of social inequity). Ethical values also differ between people and countries, and the psychological and cultural perception of facial recognition matters.

We can learn much about the emergence, development and regulation of facial recognition systems by considering how innovative technologies have been received and implemented in the past, whether the printing press in the sixteenth century or the telephone in the nineteenth. Whatever legitimate or imagined challenges are brought by new technologies, it is impossible to uninvent them. So it is important to focus on their known and potential effects, including how they might alleviate or exacerbate systemic social problems. History shows that it is the sophistication of policy and regulatory response – that includes consulting with the public and innovators – that determines success.

Historical context is equally critical to understanding the cultural meanings of facial recognition. In the 18th century, the pseudoscience physiognomy suggested that character and emotional aptitude could be detected via facial characteristics, in ways that are discomfortingly similar to the ‘emotion detection’ claims of some facial recognition systems. In the 21st century it has similarly and erroneously been claimed that sexuality or intelligence could be read in the face. Faces, it is presumed, tell the world who we are.

But technology is never neutral. And not all people have publicly ‘acceptable’ faces, or the faces they had at birth. Facial discrimination is a core element of the #VisibleHate campaign.

By accident or illness, surgery or time, faces have the capacity to change and transform. Sometimes this is deliberate. Facial recognition technologies can be occluded and confused – by masks, by camouflage (like CV Dazzle), by cosmetic and plastic surgery.

I work on the history of face transplants, an innovative and challenging form of surgical intervention reserved for the most severe forms of facial damage. Those undergoing face transplants do so for medical rather than social reasons, though that line can be blurred by contemporary concerns for appearance. Whether recipients’ sense of identity and self-hood is transformed by a new face is a subject of ongoing debate. Yet the capacity for radical transformation of the face exists.

Facial recognition technology not only raises questions about the ethical, legal, practical and emotional use of biometric evidence, but also presumes the face is a constant, individual unit of identity. What happens, on an individual and a social level, if that is not the case?

Author Bio

Fay alberti

Prof Fay Bound Alberti, Professor of Modern History, UKRI Future Leaders Fellow and Director of Interface

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Facial Recognition: From Face Blindness to Super Recognisers

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Facial Recognition: From Face Blindness to Super Recognisers

The Author

Sharrona Pearl

Sharrona Pearl

This blog is part of our series on facial recognition. Check out our first blog on this theme, by PI Fay Bound Alberti, on facial recognition software, history, and the meanings of the face, and what we can learn about this technological innovation by looking at the past. Today’s blog is written by Sharrona Pearl, and explores the scale of human face recognition, from face blindness to super recognisers.

Facial Recognition: From Face Blindness to Super Recognisers

Face recognition is a wonderful and complicated neurological process.  We are learning more about it every day.  But it’s also a deeply cultural and social and emotional and human one.  Faces are, as I’ve argued in my books and articles, a key part of how we make sense of others, build relationships, communicate, make judgements.  Recognizing faces helps with interpreting emotion.  It tells us something about where people are looking and what they might be looking at.  All this gives us cues about how to interact with others and our surroundings.  Recognizing faces can help us recognize social cues about how to act and what to do in a given situation, and with a given person.  We spend quite some time on how we present our own faces, and we imagine we know all sorts of things about others based on their faces.  The face is both a thing and a collection of things and feelings and ideas.  It has a history and that history is changing.  Face recognition, and the invention of the face recognition spectrum, is part of that history.  The naming that emerged with these categories of “face blindness” and “super recognition” helped people understand something about themselves and how they make sense of others.  They gave name to experience, and in so doing, created new kinds of experiences.  This is true of all categories, but there is special resonance to the face.  Because are faces are, or at least we think they are, who we are. 

Face Recognition

A lot of things have to happen in the brain for us to recognize faces.  It’s actually less extraordinary that some people can’t do it than that so many of us can.  People, in general, are pretty good at recognizing faces; a face may often seem familiar even when we can’t remember names or context.  For some people, it just doesn’t happen as well, and for others, it doesn’t happen at all.  And it’s one of those things that seem to be impossible to understand how it works in others.  As a person who recognises faces pretty well, face blindness just doesn’t make sense to me.  There are all kinds of metaphors and explanations and attempts: imagine you were shown a picture with a pile of lego of different lengths and colours.  Imagine the picture is then taken away.  You would certainly know and recall that it contained lego, and maybe even some broad features of color and shape.  But you are unlikely to remember precisely the order and configuration of each piece.  That, maybe, is what face blindness is like: people can remember that they saw a face, with eyes and a nose and a mouth.  But which eyes; what nose; whose mouth, disappears immediately the face is gone.  Voices, to those with an ear or who have developed this adaptation, may offer consistent clues.  Gait is often ingrained and can be linked to a particular person.  Hairstyle and shape, distinctive piercings and moles and tattoos and glasses all contain lasting resonance.  Face blind people rely heavily on such markers.  But many of these markers can change, sometimes with no notice.  That leaves face blind people without reliable ways of recognizing others; a change of hairstyle or clothing may mean that someone who was identifiable in the morning becomes impossible to distinguish in the afternoon, no matter how hard they look. 

For about 1-2% of the population, no amount of staring at a face will help.  No amount of training will help.  Colour blind people cannot be taught to see colour.  Face blind people cannot be trained to see faces.  Profoundly face blind people simply will not recall the features of a face.  Others can do it slightly better and so on and so on, with the bulk of the population mostly able to mostly recognize most faces.  Relationships help.  Repeated exposure helps.  Paying attention – for most people – helps.  Sharing a powerful moment helps.  And, while memory and face recognition are broadly unrelated at the extremes, memory, taken in conjunction with everything else, helps.  The top 1-2% of the population can do it better than anyone else.  And everyone else can’t be trained to do that either.  How odd it would be to condemn a colour blind person for not being able to distinguish red and blue.  And how odd it would be to castigate someone for failing to recognize a face, or, indeed, for recognizing only some faces rather than essentially all of them. 

Face Blindness and Super Recognition

When face blindness was first described, scientists thought that it was a pathology, a disability that some had to greater or lesser degree.  And everyone else could just recognize faces more or less equally well.  That changed pretty dramatically when Harvard post-doctoral fellow Richard Russell and his team clinically identified super recognition in 2009.  If there is a bottom 1-2%, they theorized, there is likely a top 1-2%.  Those are the supers.  And while they aren’t perfect at face recognition, whatever that means, they perform at the top end of the scale compared to the rest of the tested world.  Which means that it’s still a pretty big bucket, and that the top 1-2% of the top 1-2% are going to look significantly different than even other super recognizers.  As I discuss throughout my forthcoming book, supers are extremely good at a wide variety of face recognition skills: matching images to people or other images; aging people over time; and recalling people in different contexts and identifying them as the same.  While super recognizers do not have a photographic memory for faces, and they actually do sometimes forget a face, they do it much less than everyone else.  Really, super recognizers recall faces independent of the depth of the interaction or relationship they have had with someone.  Most of us recognize the faces of those we know and love better than anyone else.  We are more likely to recall those with whom we have shared a powerful experiences.  For supers, even a brief or fleeting or non-interaction with someone is often enough.  That doesn’t mean they recognize all faces always: it does mean they recall most faces better than others.  Even those they have encountered only briefly, and without meaningful exchanges or relationships. 

Diagnosis or Explanation?

Facial recognition does not exist in a vacuum.  We all recognize faces differently in different contexts and with different cues, even for those of us who can’t do it at all.  In some ways, actually, it’s easier now to get by without recognizing faces, especially if you spend a lot of your time interaction with others online.  (As I write this, we are two years into a global pandemic in which faces are often masked and maybe universally unrecognizable in public, and most encounters with others are on digital platforms that provide names below the faces.  As most of the world got zoomed out, a small group of people quietly celebrated the ability to always know to whom they were talking.  For face blind people, zoom was an unlooked for, unasked for gift that gave the elusive possibility of recognition.)  Recognizing people has never been harder and never been easier.  But also: there are a lot more faces now.  And we encounter them a lot more both in person and through media.  

We can know people don’t recognize faces from their testimony.  But – and this is important – there are a lot of ways to be bad at recognizing faces.  So: is face blindness a proscriptive term or a descriptive one?  Is it a diagnosis or an explanation?  The answer is, of course, yes: it is all these things.  Faceblindness, or prosopagnosia, is a very specific term generated in a specific moment in history with specific reasons, narratives, and causes.  It has to do with specific stuff in a specific part of the brain.  And maybe some of those people in the past had that stuff in their brains, and maybe not.  It’s interesting, of course, to speculate as to whether some of these case studies with associated recognition challenges were actually examples of face blindness.  Many people have made precisely those speculations.  Others refuse to. 

I, as ever, say yes and. 

Author Bio

SHarrona pearl

Sharrona Pearl is Associate Professor of Medical Ethics and History at Drexel University.  A historian and theorist of the face and body, Pearl has published widely on Victorian history of medicine, media and religion, and critical race, gender, and disability studies.  Her current book, from which this material is drawn, is on the face recognition spectrum from face blindness to prosopagnosia and is forthcoming from Johns Hopkins University Press.  This book is the third in her face trilogy, following  Face/On: Face Transplants and the Ethics of the Other and About Faces: Physiognomy in Nineteenth-Century Britain.  She is currently writing a book on “The Mask” under contract with Bloomsbury Academic.  Pearl maintains an active freelance profile, with bylines in a variety of newspapers and magazines including The Washington Post, Lilith, and Real Life Magazine.  Say hi on twitter @sharronapearl.

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The making of a blueprint. How historical, qualitative research should inform face transplant policy and practice.

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The making of a blueprint. How historical, qualitative research should inform face transplant policy and practice.

The Author

Fay Bound Alberti

In December 2021, the AboutFace team convened a three-day Policy Lab with the support of the Policy Institute at King’s College London. The Policy Institute has a track record of bridging the gap between research, policy and practice, and making recommendations to UK policy makers. But the AboutFace policy lab was not looking to shape UK government policy around face transplants. Rather, its rationale was quite different.

The making of a blueprint. How historical, qualitative research should inform face transplant policy and practice.

One of the purposes of AboutFace research is to bring interdisciplinary, international expertise to bear on some of the pressing challenges around face transplants. I developed this programme of research into the history and ethics of face transplants because I wanted to ensure that all stakeholders were brought into the discussion: people with lived experience of visible difference, qualitative researchers, and extended surgical teams. The reasons why are quite simple.

Since 2005, when the first face (partial) face transplant took place, the emphasis has shifted in ethical debate from whether it could or should happen to how it happens. Yet many of the issues raised in 2003 and 2006 by the Royal College of Surgeons are still problematic. Heavy use of immunosuppressants carry a health burden for the whole patient and are life-reducing. The estimated length that a face transplant will survive is ten years, though there are some exceptions. There is no consensus on how patients should be selected, and no real data sharing across boundaries. There is not even any agreement on what success looks like in face transplants, a subject I am talking about at the International Society for Vascularized Composite Allograft conference in Cancun this week.

Creating a Gold Standard

In bringing experts from all around the world together, we wanted to create a blueprint that makes recommendations for best practice; a gold standard in how far transplant policy and practice should be led. We were heartened by the consensus in the room, and by the simplicity – but importance – of the recommendations being made to surgical teams to ensure patients receive the best possible treatment.

We believe that this Blueprint is also an example of how qualitative, historically-informed research can help shape and inform surgical practice, and make an international impact. We have included sections on patient selections and expectations, clinical frameworks, patient support networks, public image and perception, financial sustainability and data on patient outcomes and progress.

While this report has a surgical focus, because we are reaching out to extended surgical teams and nurses around the world, we will also be working to engage patients and their families with our findings. We will be releasing a series of videos and discussion points over the coming months. In the meantime, we invite you to read the report and let us know what you think. Any questions, ideas or concerns, get in touch with us.

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Before and After? What the humanities bring to medical images

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Before and After? What the humanities bring to medical images

The Author

Graeme Heward

In this short video, Graeme Heward shares his experiences of facial surgery, and project lead Fay Bound Alberti discusses what the humanities bring to medical images.

Before and After? What the humanities bring to medical images

AboutFace cares about the experience of patients and centres them as important historical narrators in the history of medicine. While before-and-after photographs serve an important medical function in recording a physical journey, our research goes behind these images to understand patients’ journeys, including the emotional and physical journey they go through. This video features Graeme’s story, and was produced by filmmaker Barry Gibb. Graeme is a physiotherapist who sits on our Lived Experience Advisory Panel (LEAP), and who has undergone more than 30 surgeries following a diagnosis of sinonasal cancer. Below the video, Graeme reflects on his feelings when watching it back.

Please note that this video contains graphic images of facial injury. If you would prefer not to view these, you can listen to the audio file below, or read the transcript here.

“The first thing I noticed on the video was the sound of my voice.  It was a little nasally however I was articulating my words quite clearly.  Even since that video my prosthetic has been improved and we are constantly trying to improve my appearance with facial stimulation and I’m looking forward to additional magnets soon to keep my prosthetic in better apposition.

It doesn’t make me feel sad to see the video.  It shows how despite some pretty brutal surgery the body and mind does recover and offers a new beginning.  As Fay says, it is not always a smooth passage through difficult times which I’ve described previously as a rollercoaster ride. It reminds me that the prosthetic (which I love) was spawned from a nasal reconstruction disaster not the initial consideration or intent of the surgeon.  I hope that there has been some reflection of my case and that future patients might benefit from a different approach.  I’m pleased the video will be up there.  As a subject it is easier to appear on video than in person – it softens the connection and emotion.

The video shows some brutal images which demonstrate the reality of the situation.  It also shows me smiling and happy in several frames.  There are many images of different phases of facial surgery and disfigurement which help to demonstrate the journey.  It is not just me who has to acclimatise to these changes.  My partner, sons, family and friends quickly get used to my new appearances.  They say it’s still me underneath!  I think Fay describes the before and after as I feel it and my appearance and words are accurately portrayed.”

Transcript – Before and After Photographs: What the humanities bring to medical images

Graeme Heward:
My name is Graeme Heward. I’m 60 years old and I’ve been dealing with sinonasal cancer for over 10 years. I’ve had thirty-two ops, two bouts of radiotherapy, and two chemotherapy cycles, and my average op duration is 3-4 hours. I’d say that six of those ops were absolutely brutal.

Fay Bound Alberti:
Before and after images have become so commonplace in 21st century culture, whether it’s weight loss stories or environmental impact, that we don’t notice anymore that we’re being led to interpret images in this way: as an absolute change from one state to another. Behind before and after photographs of facial transformation is a messy world that often includes adjustments, pain, failures, hope, maybe acceptance. AboutFace explores the history and cultural meanings of face transplants and facial surgery, and one of the key themes that we work with is the idea of ‘before-and-after.’ We take an interdisciplinary, historically informed approach to look at what’s happening when we put together images in a particular way, including the psychological transformation that is expected to accompany a physical one in the before-and-after sequence.

Graeme:
Radiotherapy, I had twice for mopping up following tumor removal. On each session, I endured a plastic mask formed to my face and shoulders that pinned me to a solid plinth. It was horrendous and it brought me to my knees. I was referred by my ENT [ear, nose and throat] specialist to a plastic surgeon. It didn’t go well. The surgeon tried to recover the situation in a further three brutal operations. On reflection, I had a very poor, life threatening experience, with a consultant who I felt was experimenting on me.

I’ve had some crazy appearances throughout my journey. Most notable was a pedicle graft from my forehead to my nose, which resembled the shape of a penis. And the second was a flap graft, from my thigh to my face, which looked like a panty-pad stuck to my face. I’m on my third prosthetic now, in three years. Each time it is a better likeness of my former self. I feel like I’m clawing back something that had been taken away, principally by the cancer.

Fay:
Now this ordering of before-and-after, which makes complete sense from a medical perspective in showing the visible impacts of surgery, matters because it implies a journey that it is not always as straightforward as it seems. AboutFace considers the language and framing of transformative surgeries in visual images, and asks how can we connect to and explore these stories that are hidden from view? Working with people like Graeme helps us to see why it is that bringing together arts and humanities approaches, that look at the history and the ordering of medical photography, for instance, reveals new insights about the social and emotional impacts of surgery. It also helps us think about the cultural meanings of facial transformation in a more human centred way.

Graeme:
My modus operandi has always been to carry on as normal, then other people will follow suit. In ten years of facial disfigurement, I’ve had very little trouble with comments. It’s mostly staring. I’m not for adults staring, but for kids I think that it’s an opportunity to learn something new and how to behave. They’re fascinated by something different and I answer them honestly, like “where’s your eye gone?” Well, it’s a fair question! Smile and the world smiles with you. If I can laugh at myself, then other people can too.

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Diminishing their Voices: Face Transplants, Patients, and Social Media

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Diminishing their Voices: Face Transplants, Patients, and Social Media

The Author

Patrick Adamson

Public Engagement and Events Officer, Sarah Hall, writes about facetransplant patients and social media. In this blog, Sarah explores the familiar narratives that circulate in the media, and argues that the primary voice should be restored to the patients themselves, giving them control over their own narratives.

Diminishing their Voices: Face Transplants, Patients, and Social Media

A video showing a woman inside a spider monkey enclosure at El Paso Zoo, Texas, started circulating on social media in late May 2021. The woman allegedly broke into the enclosure to get a video of her feeding the monkeys Flamin’ Hot Cheetos. She did so for her social media channels. The video predictably gained a lot of attention, much of it negative. Commenters decried the woman’s reckless disregard for her own and the animals’ safety. These reactions are familiar to those of us on social media. Whether because of the relative anonymity that it affords, or because we are so strongly encouraged to share our opinions on any given issue, we are used to witnessing, feeling, any maybe even contributing to waves of collective outrage. But such moments are fleeting, and the outraged crowd will flock to a new issue before long. 

Social media is core to my work on AboutFace. The Institute of Historical Research’s History Labs+ recently invited me to speak about my work in this area. Namely, on how we present sensitive histories on our social media channels. Over the past six months I’ve come to realise that social media is capable of being far more than a tool for disseminating research. Additionally, it can be a space in which to conduct research. A valuable place to connect with trends, conversations, and public feeling. 

Drawing Parallels

It was while looking for recent tweets mentioning face transplants that I came across the video of the woman in the spider monkey enclosure, and the vitriol that followed it. I noticed that a number of angry responses mentioned Charla Nash. Nash (pictured) received a face transplant in 2016, after being brutally attacked by her friend’s pet chimp in 2009. Tweeters drew parallels between the real life attack and the potential for a repeat occurrence. However, few actually named Nash. Comments instead mentioned ‘the woman overseas who needed a face transplant’. One referenced what happened to Nash indirectly, writing ‘I see a face transplant in her future’.

Unusually, a number of replies came from British authors, who may have recently been reminded of, or learned about the event for the first time in a recently published Daily Star article. The article presented a graphic description of the attack, including audio of the 911 call made by Nash’s friend.

The news of Nash’s attack circulated widely in the US when it happened. And follow up coverage shared news of her face transplant. But coverage in the UK was limited to a few sensationalist pieces in the tabloids, while the broadsheets focused on surgical innovation. There is likely a link between the publication of the Daily Star article and the references to Nash’s attack in tweets from British authors. Tweets largely focused on the event, on the chimp, not on Nash herself, echoing the tone of the article. 

Familiar Narratives

Face transplants receive diverse treatment in social media. From flippant remarks to government conspiracies, fascination to condemnation and mockery of the aesthetic outcomes. Stories such as Nash’s circulate in public discourse according to familiar scripts. They are presented like films, featuring protagonists and antagonists, and readers treat them accordingly. Both social and news media present a fragmented view of reality, distancing audiences from the actual trauma of events. This process is exacerbated by the fact that most face transplant recipients are rarely the protagonists in their own stories. For Nash, people remember the chimp, Travis, before they remember her. They remember the attacker, not the attacked. If you Google ‘Charla Nash,’ the first result is the Wikipedia page for Travis, which remembers him both as perpetrator of the attack and tragic ‘child star.’ 

Contributing to this is the plurality of online discourse. Nash’s story, no longer simply her own, has been hi-jacked by multiple different parties. Just as some news outlets have used it to hail the victories of the surgeon leading her treatment, others have used it to mourn the tale of a wild animal raised in captivity. On social media, it circulates as a warning, a lesson against reckless contact with animals. Not long ago, it was employed to mock the people who had responded to a YouGov survey, claiming that they would beat a Chimpanzee in a fist fight. 17% of respondents answered that they would win. In these public spaces, Nash’s story is not her own, despite her efforts to present her own narrative. 

https://youtu.be/tOLaDP5UgRI

A fixed moment?

When the media, hospitals, and surgeons share news of completed face transplants, naming the patients, they catapult them onto the world stage, and directly into the public eye. Instantly, these patients’ stories are available to be picked up, claimed, shared, and transformed by others. Patients become supporting characters in other stories. I even find myself asking: were they were ever presented as something more? At AboutFace, we are concerned about this process. 

Face transplant patients are patients for the rest of their lives. There is no final ‘healed’ state, where they will no longer need medical care to monitor the donated tissue for signs of rejection. They may even have to undergo further surgeries to improve the function of their new face. But these are not the stories that are presented to the public. The people who continue to make passing, flippant remarks about face transplant, are presumably not aware of the ongoing challenges that transplant patients face. But there is no good reason that they should not be made aware. 

There is a sense, almost, that the moment the patient was presented to the media, their story became fixed in time. And it is that moment, that memory, that holds pride of place in the public consciousness. That is the moment that circulates periodically on social media, sitting below the surface until familiar details emerge in current events or conversations. Even then, it is sensationalised. These patients, who did not choose the spotlight, have been given it nonetheless.

Public Perception

It’s notable that the people referring to Nash’s story online rarely know more than the most basic details of her story, and even these details are not always accurate. As these narratives are picked up and reframed to suit the story being discussed, they take on new life. But what happened to the patient’s story in the process? 

With the distance afforded by the internet, social media users are removed from the reality of the people whose stories they co-opt. Face transplants can, in this space, continue to exist as both medical miracle and science fiction, and everything in between. The patient almost becomes irrelevant in the effort to prove a point, make a joke, or impress with a display of knowledge. But these narratives are still important to AboutFace, because they provide insight into public perceptions of face transplant. As an experimental procedure, where fewer than 50 have been performed worldwide, face transplants are still not common knowledge. We seek to understand what people know, what they want to know, and how we might contribute to more productive narratives. 

In this process, social media becomes an important research tool. We can quickly tap into the swift moving debates, opinions, and currents of public opinion. In few other spaces are people so willing to share their innermost thoughts. The anonymity afforded them provides a safety net. The nature of social media means that thoughts are shared instantaneously, without the pressure of, say, an online survey where people may seek to impress or please a reader, rather than honestly sharing their thoughts. Social media remains a performance, but it is a performance to which we have a front row seat.

Providing a Voice

When face transplant patients are not the protagonists in their own stories, something is wrong. They do not have control over the way that their narratives are told. It is time for that to change. At AboutFace, we believe that restoring the patient to the centre of the narrative is essential if we are to fully understand face transplantation and its outcomes. We speak to patients, as well as the medical teams who work with them. In doing so, we seek to place greater attention on patient reported outcomes. This means identifying ways in which medical teams can more effectively record what it means to live with a transplanted face, and what success looks like. In doing so, we will give a voice to the people who are actually at the centre of the story.

Author Bio

Sarah is Public Engagement and Events Officer on the AboutFace project. She is an experienced events manager with significant experience in the Higher Education sector, and is interested in engaging with creative methods for disseminating academic research to different audiences. She manages the social media profiles for the AboutFace project, and offers training in social media use for ECRs. Sarah is a passionate believer in the benefits of interdisciplinary research and collaboration. She is also interested in academic outreach, and is committed to making research widely accessible to non-specialist audiences. Using a combination of qualitative and quantitative methodologies, Sarah’s research is interdisciplinary and engages closely with digital humanities.

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Robert Chelsea and the First African American Face Transplant: Two Years On

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Robert Chelsea and the First African American Face Transplant: Two Years On

The Author

Fay Bound Alberti

On 27 July 2019, Robert Chelsea became the first African American to undergo a face transplant. The facial injuries that led to a transplant occurred six years earlier, when a drunk driver struck Robert’s car, causing an explosion and third-degree burns over 60 per cent of his face and body. Robert received multiple reconstructions over several years. Once they had done all they could, his surgeons suggested Robert spoke to Bohdan Pomahac and his team at Brigham and Women’s Hospital in Boston. 

Robert Chelsea and the First African American Face Transplant: Two Years On

Bohdan Pomahac and his team had performed the second partial face transplant in the USA on James Maki in 2009, and the first full face transplant in the USA on Dallas Wiens in 2011. By the time Robert was referred to the team, there had been fewer than 50 face transplants around the world, and none, as yet, on an African American patient. In his late 60s, he was also the oldest patient to date that had been considered for facial transplantation. Pomahac, meanwhile, had established himself as one of the world’s leading experts in the field. Would he and his team be able to provide the improvements in form and function that were sought by Robert: to enable him to eat and drink normally? To walk down the street without people staring, and insects falling into his mouth? To kiss the cheek of his daughter Ebony? 

The First African American Face Transplant Patient

The decision to undergo the procedure was relatively swift for Robert, though the wait for a donor took time. A devoutly religious man, Robert believed that God had paved the way for the face transplant, putting Pomahac and his team in his path. For Robert’s family and friends, the decision was less cut and dried. Ebony worried that her father had already undergone more surgery than anyone could be expected to endure – how could he voluntarily undergo more? Her mother talked her round. Her father was doing it for reasons of ‘health’; he needed to be as well as he could be, even if that meant undergoing such a radical and risky procedure. 

Robert’s transplant has been the subject of many media stories, focusing not only on the fact of his being the first African American to receive a face transplant, but also on his being the oldest such patient to date. There has been coverage, too, of the racial nuances involved; the fact that of course Robert needed a face that reflected the right skin tone for him. The hospital did not, until Robert’s operation, cover a wide range of skin tones when it came to matching donors and recipients; it took Robert’s procedure for them to rethink the implicit racism of the default White face transplant recipient. For his part, Robert has openly engaged with questions of racial inequalities in the system: the fact that for historical and social reasons there are fewer Black donors of all kinds than White. This gives Robert’s journey an additional sense of purpose: perhaps his media profile can pave the way for more public conversations about organ and tissue donation. 

Robert Chelsea. Image courtesy of Brigham and Women’s Hospital

The Hidden Costs

When I spoke to Robert and his daughter Ebony, and to Robert’s godson Ricky, as well as some of Robert’s friends in advance of the second anniversary of his transplant on 27 July 2021, I was struck by the thoughtful reflectiveness of everyone concerned, and by the love and support that surrounded him. I was also reminded that Robert’s journey towards health is an ongoing one. One of the core concerns of the AboutFace project is the largely neglected cost for patients: social, psychological, financial, and physical. Because while most media reports focus on such innovative procedures as surgical milestones, and the visual transformations that can take place, there has been far less attention given to the lived experience of patients and their loved ones. 

A face transplant is a highly visual shift from one form of appearance to another. Less visible, but equally important, are the behind-the-scenes challenges that patients must go through every day. At a physical level, there is a punishing regime of medications that include the immunosuppressants that prevent the rejection of donor tissue, and also come with a wide range of side effects besides the body’s weakened immunity to disease. In the first instance these include loss of appetite, nausea, vomiting, and trembling. Immunosuppressants can also cause other conditions, including diabetes and kidney disease. 

Alongside these physical challenges are the social costs, as a patient is generally unable to work, as even when feeling relatively well. Being a long-term patient is time-consuming, and individuals rely on a steady stream of caregivers, paid and unpaid. Financially, the costs of those caregivers, of the medications, of travel to and from the hospital and day to day living expenses can rise far beyond that which is covered by medical insurance. Indeed, insurers do not tend to accept face transplant patients because it remains experimental medicine; the majority of such operations in the US have been paid for by the military. 

Quality of Life for Patients

It is critical that we, as a society, and within medicine, start to acknowledge these hidden costs, that are not as transformative, dramatic, or immediately visible as the surgical procedure, but equally important to determining how far face transplants can be counted as successful. Quality of life for face transplant recipients must include not only some of the functional and psychosocial aspects of the procedure, in this case Robert’s ability to eat and drink normally, to kiss his daughter, and to avoid the stares of others, but also the implications for long-term health and care. Most face transplant recipients in the US (and potential recipients) need to fundraise to provide for this care, though its requirement can be seen as a side effect of the procedure itself. Quality of life must also consider the psychosocial implications of becoming a lifelong patient, with all the challenges to identity and meanings that this brings. 

The work that we are doing at AboutFace, in collaborating with surgical teams, patients and their families, ethicists, sociologists, psychologists and people with lived experience of visible facial difference, shows how critical stories like Robert’s are to the historical framing of face transplants. Medicine does not, and has never, taken place within a vacuum. Like all other aspects of society, it is influenced by beliefs about race, ethnicity and gender (whether in the question of skin tone or  presumptions about acceptable female appearance), and it is intensely emotional. Not only for patients, whose journeys towards health can be arduous and circuitous, in terms of outcomes as well as the emotional stamina needed to keep going, but also for surgical teams, who balance ‘risk’ and ‘need’ alongside their own personal and professional desires to progress the field. 

Measuring Success

Historically, the experience of patients has not been core to evaluating the success of a surgical procedure. Christiaan Barnard’s first successful heart transplant in 1967 was not so successful for the patient Louis Washkansky, who died after just 18 days. Of course, surgeons care about their patients, but the long-term effects on the lives of patients and their families tend not to be prioritised when evaluating the clinical outcomes of procedures that are innovative and path-breaking. 

In part this hierarchy reflects the fact that ‘quality of life’ measurements (like many categories associated with ‘mental health’) are inherently subjective, but it also reflects the ways medicine advances by implicitly prioritising the future needs of the many over the present few. Indeed, it is only within the last couple of years that surgical teams have begun collecting patient reported outcomes, and comparison between countries and institutions remains rare. We urgently need a more open and balanced discussion of human experience, and historical, comparative analyses of patient-reported outcomes alongside clinical findings, to evaluate the evolving role of face transplants. Listening to people like Robert Chelsea is a good place to start.

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