Thursday, November 21, 2013

Explore the Source: Epidemiologists at Work




this book and provided me a reviewer's 
copy. They gave no renumeration or 
editorial guidance for this review.
African Water Pump H53
Acrylic byMariah Hamman
posted: Eckhart Public Library 2012

How to save millions of people? Hire epidemiologists—medical detectives who investigate: foodborne and food industry illness, increased and unexplained mortality rates, higher than expected rates of pneumonias and fevers, and global migration of highly resistant organisms, among many other events. Often they work behind the scenes—behind newspaper headlines with sensational ledes.

Epidemiologists are day-to-day, often meticulous personnel at local, state, federal, and global health organizations who observe patterns of disease, discuss their concerns with colleagues, involve experts from several disciplines and organizations, talk to patients and families affected by illness, enter data into databases and analyze it, study maps, use statistics and graphs to see patterns, and discuss and publish their findings so that others can learn. They are detailed people who love medicine, who love to solve puzzles, and who help to control outbreaks and prevent reoccurrences.

Alexandra M. Levitt in Deadly Outbreaks: How Medical Detectives Save Lives Threatened by Killer Pandemics, Exotic viruses, and Drug-Resistant Parasites (Skyhorse Publishing, September 2013) asks:
"What type of person is ready and able to pit his or her wits against the endless inventiveness of infectious microbes?"
She answers this question by highlighting epidemiologists—their lives, the people they work with, and their science.

John Snow (the father of epidemiology) was an inquisitive person too, who in 1854 instructed the Broad Street Directors to remove the pump handle from the Broad Street pump as it was, according to his astute observations, allowing people to drink Cholera-contaminated well water. He observed and documented and analyzed what was happening to people of Victorian Soho London. In the words of Steven Johnson, author of Ghost Map: The Story of London’s Most Terrifying Epidemic—and How it Changed Science, Cities, and the Modern World,“…[It was the] first time a public institution had made an informed intervention into a Cholera outbreak based on a scientifically sound theory of the disease.”  His scientific methods and communication of his conclusions saved hundreds of lives at that time, and it could be argued that his methods, that live on now, have saved millions more. His search for source (the pump!) and his action (remove the pump handle!) led to epidemiology.

Much like Maryn McKenna’s 2004 book Beating Back the Devil: On the Front Lines with the Disease Detectives of the Epidemic Intelligence Service, the people and the circumstances in which they live are central to the story. However, McKenna’s book focuses, with a more finessed narrative, on the training and experiences of the Center for Disease Control’s Epidemic Intelligence Service. Dr. Levitt’s well-written book provides a more state and local epidemiologist’s perspective on what an epidemiologist does.

Each epidemiological case has clues, a beginning. In this book, there are seven chapters and an epilogue, with eight beginnings that draw the reader in:
“Medical detective Annie Fine was reluctant to venture out to Queens for a routine check on a few encephalitis patients at a neighborhood hospital in Flushing.”
“Patrick J. McConnon, the U.S. CDC Regional Southeast Asia Coordinator for Refugees, was sick to his stomach, dreading the decision he had to make.”
“In March 1981, the coroner’s office of the Province of Ontario alerted the Toronto police to four suspicious deaths in cardiology Ward 4A of the hospital for Sick Children, a hospital that specializes in caring for babies with complex heart disease.”
“On Monday, August 2, in the bicentennial year of 1976, an official of the Pennsylvania chapter of the American Legion reported something strange: same-day obituary notices for four middle-aged legionnaires, briefly sick with an influenza-like illness, who had attended a convention in Philadelphia during the third week in July.”
“Medical detective Craig W. Hedberg first learned about the rise in food poisoning cases from a microbiologist at the Minnesota state lab lab [sic] who visited his office in late September, 1994.”
“In September 2007, an attending physician at the Austin Medical Center (AMC) in Austin, Minnesota, examined a patient with numbness, tingling, fatigue, and weakness in the legs and feet—symptoms that suggested damage to the peripheral nervous system, the network of nerve cells that transmit information between the brain and spinal cord (the central nervous system) and other parts of the body.”
“Dr. Thomas Hennessy remembers the spring of 1993 as green, lush, and beautiful, in the special way of desert lands after rain.”
“Because new microbes continue to emerge, we must always be prepared for the unexpected. As this book goes into production, international investigations are underway—one in the Middle East and one in China—involving new respiratory diseases with high fatality rates and the potential for global spread.”
The epidemiologist investigates as seen here in Chapter 3: Sorrow and Statistics:
“What could medical detectives do that the Sick Kids doctors and the police had not already done? The doctors had focused on the details of each baby’s illness, finding a natural reason for each death. The police, on the other hand, had focused on a particular suspect, seeking legal evidence to build a case against her. The epidemiologists viewed the evidence from a different angle. Unlike the police or the doctors, they looked at all of the deaths at once, as part of a single mission, trying to figure out what all of the cases had in common—somewhat like an FBI analyst examining deaths linked to a single serial killer.”
Epidemiologists come up with a potential source (an aha! Or a “pump handle” moment) and take action, like in Chapter 6: Red Mist:
“Staring spellbound at the head table and its workers—who looked both strong and vulnerable—Lynfield said to Wadding, ‘Kelly, what do you think is going on?’ Wadding responded by deciding, then and there, to stop using air-blasting machinery to harvest brains. On the spot, he ordered the device dismantled and brought to his office. He also agreed to provide the head table workers with additional protective equipment.”
Sometimes epidemiologists stumble upon a new organism, as Chapter 4: Obsession or Inspiration details:
“Armed with the new culture technique and silver stain, the CDC scientists demonstrated unequivocably [sic] that the new microbe was a gram-negative bacterium rather than a ricketssial bacterium, although it turned out to be closely related genetically to Coxicella burnetii—the rickettsia that causes Q fever. (Gram negative bacteria are characterized by an inability to take up certain dyes because of the structures of their cell walls) It was named Legionella pneumophila (“lung-loving”), in honor of the American Legionnaires. Although many affected groups do not want the stigma of having an organism or disease named after them, the leaders of the American Legion decided that the name would honor their fallen colleagues.”
The science in Deadly Outbreaks is rich and understandable. It may be a bit tough for the uninitiated, however, but the people-centeredness of the stories will bring in most curious readers. There are two infectious disease errors I assume (given Dr. Levitt’s expertise in infectious disease) were due to unnoticed autocorrect functions within the word processing program used to write the book: Typhoid Mary was said to have typhus. She was a Salmonella typhi carrier, not a typhus carrier. And mycoplasma was once misspelled as micoplasma.

What will appeal to many readers is that Dr. Levitt is well read and steers the reader to interesting and lesser known resources:
“…Hedberg remembers working long but productive hours to make sure more people did not become sick. He also recalls that once the tainted meat was off the market and things began to wind down, MDH [Minnesota Department of Health] shut down the investigation for a week to give him time off to get married. A few years later, this unusual foodborne outbreak became the topic of the last New Yorker article by Berton Roueché, the author of Eleven Blue Men, a classic collection of outbreak stories from the 1940’s and 1950’s5
Deadly Outbreaks also has a note section in the back, with further references. There are several photographs of the people involved in the investigations as well as short biographies of each.

Deadly Outbreaks is an important addition to the science literature, as it highlights epidemiologists via a new perspective, and it details who they are and how they do their work: from clues, to source, to action.

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