Reading Between the Lines

Steve Schoenbaum writes: "Inside the Outbreaks", Mark Pendergrast's wonderful history of the Centers for Disease Control's Epidemic Intelligence Service (EIS), can be read on many levels. I confess that as a former EIS officer (1967-1969), personally familiar with most of the "elite medical detectives" of the first few decades, I tended to read it "between the lines". I found myself recalling many personal incidents, interactions with others, and themes mentioned but not necessarily fully developed in the book. I'd like to consider a couple of those here:

Early on in "Inside the Outbreaks", Alex Langmuir's description of epidemiology as the science of long division gets mentioned as does the classic four-fold table (e.g., in the context of common source epidemics such as pot-luck suppers, a matrix for each food item served would have two columns - "ill", "not ill" - and two rows - "ate the item", "did not eat the item"). What comes through by implication in the book is the extraordinary inventiveness that EIS officers and other epidemiologists have exhibited over the years in getting usable numerators and denominators. The method may sound simple, but there are several varieties of epidemiologic studies - the book predominantly mentions cohort and case-control - and one can spend a lifetime coming to an understanding of how best to use epidemiologic methods to address important issues. And, the fact that the EIS has been able to foster so many contributions from people who start out with a two-year term of service and a one-month introductory course, generally taught by peers who have been in the program for just a year themselves, speaks to the robust organization of the program itself including to mention a few, its selection process, development of tools such as the course itself including its use of the case-method type of teaching that Karen Starko describes in her blog post (June 23, 2010), as well as software and other resources EIS officers can use in the field, consultative backup, and development of reports that do not just lead to publications about the issue at hand but also provide the basis for program evaluation.

Some years ago Alex Langmuir was asked to participate in an oral history project, I believe by the National Library of Medicine. When his contribution was completed, there was a ceremony in Boston at the Countway Medical Library, and several of his associates and friends were asked to speak in his honor. I, in turn, was honored to be one of those. At that point, most of my activities were related to management in a large HMO. I had left academia and had taken my first major management position after almost a decade and a half of being an epidemiologist. It was beginning to dawn on me that my work and experiences as an epidemiologist were informing my management career. Indeed, I believe that most epidemiologic projects require developing and managing teams - a theme that is nicely and plentifully illustrated in "Inside the Outbreaks". In preparing remarks for Alex's ceremony, I was able to reflect on the fact that in my opinion he was an excellent manager. None of us is perfect; and "Inside the Outbreaks" does a nice job at painting a portrait of Alex both at home and in the workplace "warts and all". But, I think that readers of the book will recognize that the EIS was a classic start-up/entrepreneurial venture and that its founder was able to grow it into a significant enterprise, many of whose activities and processes have proven durable for decades.

One thing that goes back to the earliest days of the EIS and Alex's influence, and comes across well in the book, is the notion of translating epidemiologic information into action. Alex had a strong bias towards action, a characteristic of good managers, and that bias fortunately has also persisted over the decades. I believe it has also been injected into many EIS officers, or if already present in our personalities, enhanced by the EIS experience and the opportunities to act that it presents.

In my opinion, Mark Pendergrast has done an excellent job in showcasing the EIS and its history without overly confounding it with the "co-history" of the Centers for Disease Control or the US government as a whole. Yet, these larger forces not only provided the environment in which the EIS did and does function, but also directly affected programs, decisions, and possibly attitudes. The book describes some of the issues around public disclosure of information learned by EIS officers, but it would take a separate analytic vs. an historical approach to really get at the degree to which some of the specific incidents recounted, e.g., what gets included in the MMWR, how to handle the (dis)continuation of a clinical trial, etc, reflect decisions at the level of the EIS vs. CDC vs. some higher level of government. CDC programs and thus the experiences of EIS officers have certainly been affected by higher level decisions. Although CDC still published abortion surveillance reports, I believe that activities recounted in the book that are related to abortion surveillance in the period following Roe v. Wade (1973) changed dramatically as a result of U.S. government policies related to family planning and abortions. Similarly, I suspect that CDC could have, and EIS officers could be involved in, more activities related to injuries resulting from handgun use were it not a controversial area of public policy. CDC is not the only federal agency that is tractable to pressures from strong outside interests. Some readers of this blog may recall that the former Agency for Health Care Policy and Research (AHCPR) was threatened with total loss of funding and almost went out of existence in the mid-1990s because of controversy about its clinical guidelines activities, particularly one for management of back pain, and was reorganized into what is now the Agency for Healthcare Research and Quality (AHRQ), an agency that funds the development of evidence about clinical practices but does not synthesize that evidence into clinical guidelines.

Another theme that comes across well in "Inside the Outbreaks" is that while it is now trendy to talk about globalization, the EIS has had a global perspective since its earliest days in the 1950s and continues to operate and have a global influence directly or through its alumni and "friends" in other countries. That said, I also sensed, probably reflecting my EIS experience, the objective of epidemiologists mentioned in the book about going upstream to find problems that need addressing at their source, and the incidents described in the book, an opportunity for action that has not yet been taken: Beginning with CDC's assistance in the 1950s for a tidal wave or tsunami to the malnutrition evaluations in what had been Biafra to very recent involvement in the earthquake in Haiti, not described in the book, it has been common to include epidemiologists in aid efforts when responding to disasters around the world. Yet, as Hurricane Katrina showed within this country and as appears to be the case with events in other countries, both the national and international responses appear to be developed ad hoc and often appear uncoordinated. Just as we finally began to recognize a little more than a decade ago with the appearance of H5N1 (Avian) influenza that it was likely that someday there would be another influenza pandemic and that general pandemic preparedness/planning was an important priority, in reading through "Inside the Outbreaks" it dawned on me that international planning for responses to various types of disasters - e.g., floods and earthquakes - makes enormous sense. We may not know when the next will occur, but we know there will be another; and it would be prudent to have designated leaders of the relief efforts. Epidemiologic analysis of prior events would make it clear what the priorities would be for providing certain types of services in a logical order - e.g., arranging for control of air, sea and land traffic to the affected area, handling the press that will predictably arrive, assuring that the type of goods sent are appropriate to the type of disaster and local conditions (hot/cold climate, etc, etc).

I could go on, but I suspect that readers have already gotten my main messages that "Inside the Outbreaks" is an excellent recounting of the history of the EIS, an important U.S. government-sponsored activity that has influenced the lives of a few thousand persons lucky enough to have been in it, and also a highly provocative book. Readers get an extremely clear picture of the contributions possible from the social science of epidemiology and how that science is applied by its practitioners. I would recommend it as interesting, informative, even entertaining, reading.