Number-Crunching at the EIS and Why Public Health is Politics

Mark Pendergrast writes: Thanks to commentators Liz Borkowski, Karen Starko, Steve Schoenbaum, and Mark Rosenberg for their thoughtful posts, though it appears that Mark Rosenberg's post got cut off after his first-paragraph query asking why anyone would go into the field of public health. I will wait to respond to his post once I see him answer his own question! In the meantime, there is much to talk about. I (Mark Pendergrast) will respond to parts of what Liz, Karen, and Steve wrote in order, along with other blogger comments.

Let me respond first to a blog comment from John Willis, who wrote: "This sounds like the basis for the show Medical Investigation, which is just the kind of superhero style TV show about the CDC that you imagine. I thought when I watched the show that it was far-fetched - a kind of House for epidemiologists with as much connection to the real world of outbreak investigation as House does to internal medicine - but perhaps I judged it too soon."

Well, Inside the Outbreaks has indeed been optioned for a television series, though that apparently doesn't mean that it will necessarily happen. I watched a few episodes of the short-lived Medical Investigation and was disappointed in the show, since it was, as Willis thought, pretty unrealistic. In fact, the Epidemic Intelligence Service folks told me that at first they were distressed that (for unknown reasons) the TV show placed the EIS-type officers at the National Institutes of Health instead of the CDC. But when they saw the show, they were relieved. My main problem with Medical Investigation was that they often presented the epidemiologists as superhero clinicians who were actively caring for the patients. While some EIS officers have helped to care for patients during the course of an investigation, that isn't their job, and it is rare.

The super-hero cover of Inside the Outbreaks is misleading as well, showing a Clark Kent/Superman look-alike dressed in a lab coat, triumphantly holding up a test tube in a Eureka moment. That too rarely happens, since most EIS officers do not do lab work. In fact, if they had shown a realistic cover, it would have perhaps featured a photo such as this picture of Brad Hersh during a 1991 measles outbreak in Colorado. He stayed up most of the night crunching data in his lonely motel room, with papers spread all over the bed.

As mundane as that sounds, such number-crunching ("grunt work," as Liz puts it) lies at the heart of disease detection and epidemiology in general, and it often is quite urgent and dramatic, as Karen points out - it can mean life or death for someone you have never met. Take, for instance, the story of E-Ferol. Here is an excerpt from Inside the Outbreaks:

Vitamin E Shots

In March 1984, an Ohio hospital notified the CDC that three premature babies had yellow skin, bloated stomachs, low platelet counts, enlarged livers, and kidney failure. Two had died. Despite extensive testing, no infectious cause could be found. Then a Tennessee hospital notified the CDC of a similar outbreak in its neonatal intensive care unit. Three of the eight premature babies had died. Walter Williams, a recent EIS graduate, was dispatched on April 3.
At the Tennessee hospital, Williams pored over the premature babies' charts. Working 18-hour days, he finally found what he was looking for. All of the sick infants had received a new intravenous vitamin E preparation called E-Ferol. Born with low vitamin E levels, premies had traditionally received supplements by intramuscular injection. E-Ferol, licensed in December 1983, allowed easier administration through an IV tube. Williams notified EIS officer Bob Gaynes, who was still working the Ohio cases, in which he soon found an association with E-Ferol. A few days later, a third hospital called the CDC from Spokane, Washington, to say that four premature babies had died there. They too had been given E-Ferol.
A national recall halted the epidemic. The FDA had approved E-Ferol without testing because its constituents were similar to other harmless products. "The pharmaceutical industry and federal regulatory agencies should give special consideration to evaluating the safety of new medications that will be used to treat infants," Williams and Gaynes wrote in their paper on the outbreak.

You can see how urgent this matter was, but Walter Williams solved it by painstakingly compiling notes from hospital charts. One of the problems I had with writing this history of the EIS was space. I simply didn't have room for so many personal quotes and observations. Here is what Williams told me: "I found the answer late at night, in a room with no windows. My eyes were gritty. Every night had been that way. I called my supervisor at CDC that night, then redid the calculations back in my hotel room. I had a programmable calculator made by Texas Instruments, which had a card reader, but it wasn't working. So I had to plug in the numbers for it. It didn't look right to me. When I did it the last time and confirmed all numbers, the statistical significance was very high. It was this product and nothing else." So there are indeed plenty of Eureka moments for disease detectives.

Liz wrote that EIS officers are "often young and willing to take risks." True. When the program began in 1951, most were in their late twenties. Nowadays they are more likely to be in their mid-thirties, but many do appear to have a "certain immortality complex," as EIS alum Jim Gale put it in the book (he was talking about jumping into a grave to take a sample from someone who had died of a particularly virulent plague bacillus). Although quite a few EIS officers have caught the diseases they were investigating, only one EIS officer has died in the line of duty, and that was Paul Schnitker, who died in 1969 as his airplane blew up while approaching Nigeria, probably from a terrorist bomb in luggage.

I recently had dinner with John Schnitker, Paul's brother, in Washington, DC, where he works for the State Department. There is a Schnitker award given each year to an EIS officer who has made a major contribution in international health. John told me that he has kept tabs not only on the accomplishments of each winner, but the nominees, and he is continually amazed at what EIS officers have done.

Near the end of her post, Liz quoted the beginning of my section on Karen Starko's Reye syndrome investigation, which was particularly nice, since Karen turned out to be the first EIS alum to chime in here. And Liz concluded: "Inside the Outbreaks does a great job celebrating the combination of heroic and mundane work that goes into identifying and preventing disease. It's also a great way to learn about epidemiology and why it's so important."

I certainly agree, but I wanted to point out something else about that Reye syndrome affair that is frustrating. Although Karen's and subsequent CDC studies clearly demonstrated that giving children aspirin caused the vast majority of Reye syndrome cases, the CDC has no regulatory power. The FDA gave in to pressure from the aspirin industry and delayed a warning label on children's medicine containing aspirin for five years, during which nearly 300 more children died of Reye syndrome in the United States. Here is that section, followed by a cartoon from the book:

The aspirin industry demanded more studies and successfully delayed a warning label on salicylate-containing medication until 1986. From 1981 through 1985, over a thousand U. S. children contracted Reye's syndrome, with 291 deaths. Up to a third of the survivors probably suffered permanent brain damage.
Publicity about the hazards of aspirin, including that generated by the EIS officers, gradually reduced its use for children, so that Reye's cases in the United States fell from a peak of 555 in 1980 to 36 in 1987, and finally to just two cases in 1997, by which time most children's medication no longer contained aspirin.

So let me throw out a question to readers. Should the CDC have regulatory power? That would mean that those responsible for investigations would also be responsible for regulations, which might lead to conflicts of interest. That issue arose over whether the CDC should not only advise on vaccine administration but should also investigate adverse reactions to vaccines. Some argued that this was like letting the airlines run the FAA (Federal Aviation Administration.)

I don't have much to add to Karen's post on the importance of the case study method. Amen! In July 2005 I sat in on most of the EIS training, and it was the afternoon case studies that really had an impact. The new officers were fed information a little at a time, then asked for conclusions. It really made everyone think so hard that I could practically see the smoke was coming out of their ears. I must admit that I hope Inside the Outbreaks will be picked up as a supplementary textbook by universities and schools of public health to be used as a treasure trove of such case studies, or at least as the basis of intense discussion.

Steve Schoenbaum observed that the 2 x 2 table (who ate or didn't eat? Who got sick and who didn't) lies at the heart of epidemiological investigations. "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." That is certainly true, and even after five years of researching and writing about the EIS, I am certainly no expert on it all. But it might be worthwhile to discuss the difference between cohort studies and case control studies, if anyone wants to take that on. I would be willing to give my short version to kick it off.

Steve also observes: "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." That's an interesting and important point. I was afraid, in writing the book, that it would make it sound as if EIS officers came in like the Lone Ranger and solved everything alone. Instead, they have to function as members of a team. They must be culturally sensitive, establishing good working relationships quickly. That doesn't always happen, of course, and some state health departments resisted calling "Langmuir's storm troopers," as one famously put it. By and large, though, EIS officers learn a great deal about management skills by necessity.

"Translating epidemiologic information into action" is, as Steve notes, the heart of the enterprise. Yes, you need to conduct surveillance, to find baseline data. You need to trace epidemic curves, to figure out how the disease was transmitted. But then you have to make recommendations about stopping it in its tracks, if possible. As I pointed out in the concluding chapters of the book, that becomes more and more difficult when you are dealing not just with microbes, but with human behavior, which is a good deal more difficult to combat or modify. That, too, is another good discussion-starter.

Steve makes another invaluable point. "CDC programs and thus the experiences of EIS officers have certainly been affected by higher level decisions." That's putting it mildly! Here's a funny story. I want to speak to Rotary Clubs about the book, since they are such strong and important supporters of polio eradication, one of the things I wrote about. But when I called a local Rotary Club in the Atlanta area, the president said, "We usually have political speakers," and he declined. I tried to explain that public health is politics, and some of the most important (and frustrating) politics you can encounter. Comments and specific examples, folks?