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Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service

Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service

by Mark Pendergrast

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Since its founding in 1951, the Epidemic Intelligence Service has waged war on every imaginable ailment. When an epidemic hits, the EIS will be there to crack the case, however mysterious or deadly, saving countless lives in the process. Over the years they have successfully battled polio, cholera, and smallpox, to name a few, and in recent years have turned to the


Since its founding in 1951, the Epidemic Intelligence Service has waged war on every imaginable ailment. When an epidemic hits, the EIS will be there to crack the case, however mysterious or deadly, saving countless lives in the process. Over the years they have successfully battled polio, cholera, and smallpox, to name a few, and in recent years have turned to the epidemics killing us now—smoking, obesity, and gun violence among them.  The successful EIS model has spread internationally: former EIS officers on the staff of the Centers for Disease Control have helped to establish nearly thirty similar programs around the world. EIS veterans have gone on to become leaders in the world of public health in organizations such as the World Health Organization.  Inside the Outbreaks takes readers on a riveting journey through the history of this remarkable organization, following Epidemic Intelligence Service officers on their globetrotting quest to eliminate the most lethal and widespread threats to the world’s health.

Editorial Reviews

Publishers Weekly
Plucky epidemiologists track the world’s ailments in this hectic public health saga. Pendergrast (For God, Country and Coca-Cola) chronicles the exploits of the doctors, nurses, statisticians, and sociologists of the Centers for Disease Control’s Epidemic Intelligence Service, who jet around investigating the causes and remedies of disease outbreaks from Alabama to Zaire. Looming large is the ever-present, life-threatening problem of diarrhea, whose outbreaks they trace variously to contaminated water, iffy tofu, and Oregon cultists who in 1984 sprinkled salmonella into restaurant salad bars. The investigators also take on more exotic cases, including Ebola outbreaks, the post-9/11 anthrax letters, and a grade-school itching epidemic that turned out to be mass hysteria. These epidemiologists have also led long campaigns to eradicate smallpox—in Pendergrast’s telling, an epic struggle against both germs and cultural prejudices—and tried to abate social ills like smoking, obesity, and gun violence. There’s not much story-telling frippery in Pendergrast’s episodic six-decade narrative, just bare-bones accounts of barely individuated sleuths busting one microbial perp after another by collecting samples and conducting surveys. Still the scientific fight against these cunning, deadly pathogens makes for an often engrossing browse. Photos. (Apr. 13)
Library Journal
Pendergrast (Uncommon Grounds: A History of Coffee) turns his focus to a department of the Centers for Disease Control that investigates outbreaks of illness around the globe. Formed in 1951, the Epidemic Intelligence Service (EIS) originated during the polio years and progressed through anthrax, salmonella, rabies, smallpox, HIV, and Ebola to the present day. You name it, they identified it. Appealing to CSI geeks, the individual stories unfold as mysteries: What is causing this outbreak of paralysis or death? Why are all of the high school kids or factory workers getting the flu? The EIS investigated norovirus on cruise ships and malaria in Niger. VERDICT A great reminder of the importance of public health, both in the United States and around the world, this is good reading for those who wonder whether vaccinations and other simple disease preventatives such as clean water and mosquito nets are relevant today. The zippy manga cover and engrossing tales will pull in nonfiction readers not usually up for medical history.—Elizabeth Williams, Washoe Cty. Lib. Syst., Reno, NV
Kirkus Reviews
Pendergrast (Mirror Mirror: A History of the Human Love Affair with Reflection, 2003, etc.) provides an exhaustive account of the "shoe-leather epidemiologists" who trek to the world's troubled spots when a serious or unusual disease strikes. The author digs deep into the archives of the Centers for Disease Control and Prevention (CDC) to produce an impressive, occasionally awe-inspiring narrative about the CDC's Epidemic Intelligence Service. The organization is comprised of idealistic young men and women who sign up for two years of training and field work, postings during which they can face Ebola in Africa, bird flu in Asia or other more routine clusters of salmonella food poisoning in America. When EIS was founded in 1951, it was a haven for doctors seeking to avoid the draft for the Korean War, and EIS recruits were envisioned as first responders in the case of biowarfare. The early EIS decades were largely devoted to infectious outbreaks-bat rabies, Asian flu, oyster-borne hepatitis, etc.-and EIS sleuthing then and now looks at patient histories and environmental clues, often conducting case-control studies. Pendergrast does not gloss over the moral shortcomings of the early years-the infamous Tuskegee study, vaccines tested on prisoners or institutionalized children-nor does he ignore the role of bureaucratic in-fighting and politics. The author celebrates EIS's successes and occasional triumphs-like the eradication of smallpox-and the commitment, intelligence and passion of its trainees and alums. Fans of medical mysteries will find scores of EIS case histories to slake their appetites in this meticulous history. Agent: Lisa Bankoff/ICM
From the Publisher

"Pendergrast ably recounts the last half-century of these [EIS] cases in an episodic fashion, complete with the mystery, intrigue, and gory details of your favorite police procedural drama." --SEED

"…the scientific fight against these cunning, deadly pathogens makes for an often engrossing browse." --Publishers Weekly

"Fans of medical mysteries will find scores of EIS case histories to slake their appetites in this meticulous history." --Kirkus Reviews

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IN FEBRUARY 1951 Alexander Langmuir, the epidemiologist for the Communicable Disease Center (CDC) in Atlanta, Georgia, delivered a lecture at the Kansas City Medical Center. “Many pathogenic agents may be grown in almost limitless quantities and may be dispersed into the air as single cells,” he said. Langmuir bent his six-foot-two-inch frame over the lectern, his booming baritone filling the hall. “The purposeful creation of such clouds is biological warfare.” He described how atomizers could spray dangerous microbes in crowded enclosed spaces and how bombs could create smoglike pathogens that would hang over a city for hours. He spoke of contaminated water systems and of food infected at a banquet. “The planning of appropriate defensive measures must not be delayed,” Langmuir advised.

The press had warned of biological warfare since 1946. But with the start of the Korean War in June 1950, fear and rhetoric escalated. By early 1951 Langmuir had convinced the federal government to support a ready-response team at the CDC. In June 1951 American soldiers in Korea began dying of a mysterious infection that started with high fever, aches, nausea, and vomiting. Then victims’ blood vessels burst, causing internal and often external bleeding. The infection, dubbed Korean hemorrhagic fever, affected twenty-five thousand United Nations (mostly American) troops, killing nearly three thousand of them during the course of the conflict. Fear of this new epidemic disease solidified funding for Langmuir’s trainees.

The program was named the Epidemic Intelligence Service (EIS), deliberately employing a military term and implying a comparison with the recently created Central Intelligence Agency. The two-year EIS experience in the U.S. Public Health Service Commissioned Corps would satisfy the new obligation for doctors to perform military service. Langmuir suddenly had bright young physicians who did not want to go to war begging to join the CDC.

A Shoe-Leather Epidemiologist
Born in 1910 in Santa Monica, California, and raised in Englewood, New Jersey, Alexander Langmuir graduated from Harvard and went to Cornell University Medical College. After finishing his internship, he began a career in public health. Before the war, he practiced what he called “shoe-leather epidemiology” in New York State, going into the field to investigate epidemics of polio, tuberculosis, pneumonia, and other diseases. During World War II he was tapped by the army to serve on the Commission on Acute Respiratory Diseases based at Fort Bragg, North Carolina. The commission feared another massive influenza epidemic such as the one that had killed so many in 1918. No such pandemic materialized, but the soldiers, packed in crowded barracks, provided ideal subjects for Langmuir’s studies of acute respiratory disease epidemics.

Armed with a high-security clearance, Langmuir was also admitted into the top-secret confines of Camp Detrick (renamed Fort ¬Detrick in 1956), in Frederick, Maryland, where military scientists experimented with infectious agents, trying to develop strategies to combat biological warfare if the enemy unleashed it, as well as preparing to inflict retaliatory epidemics.

A Happy Hunting Ground
The CDC was three years old when Langmuir arrived there in 1949, lured from an associate professorship in epidemiology at Johns Hopkins. His friends lamented his commitment to this “dying field,” since antibiotics and vaccines presumably would solve everything. Langmuir countered, “I firmly believe that in the field of infectious diseases there is a happy hunting ground for major discoveries and contributions,” and the CDC’s broad mandate impressed him. “The range of opportunity, the potential was obvious,” he said later, “and with my considerable self-confidence, I had no trouble going.”

“Considerable self-confidence” was an understatement. “People knew when he entered a room,” Langmuir’s daughter Lynn recalled. “He tipped the boat. You had to scramble to keep your equilibrium.”

An EIS alum spoke of others quailing before “the peals of Langmuirian thunder.” His successor as the head of the program described Langmuir after his death as “visionary, clairvoyant, tenacious, well-prepared, scientifically honest, and optimistic.” Others used adjectives such as “loud, intimidating, pompous, bombastic, aggressive, and domineering.” Yet most agree that without Alexander Langmuir’s strong leadership and vision, the EIS program would never have endured.

Epidemic Twists and Curves
In tracing epidemics, Langmuir espoused what came to be called a cohort study of a carefully defined group of people (Who attended the church supper?), comparing their behavior (What did they eat? Where did they go? Who did they associate with?) and looking for key differences between those who had become ill and those who had not. Sometimes through such comparisons, the cause of an epidemic became obvious. It was the potato salad!

Langmuir stressed the importance of long division to find the rate of a given disease in a particular population—the number of ill over a defined period of time as a numerator and the population at risk as a denominator. “Stripped to its basics,” he said, “epidemiology is simply a process of obtaining the appropriate numerator and denominator, determining a rate, and interpreting that rate.” Thus, the three essential elements were time (when were people exposed and when did they become ill?), person (who was affected in what defined population?), and place (where did the epidemic take place?).

But how do you know that an epidemic is occurring? First, you establish the “normal” rate of disease for that area. Langmuir talked about the importance of routine disease surveillance to establish baseline data and to look for anomalous blips.

Traced on a time line that tracks the number of accumulating daily cases, most epidemics form a classic bell-shaped epidemic curve. In the simplest version, an outbreak begins in a particular community with an index case, spreads to others, reaches a peak, and then gradually burns itself out, as susceptibles either survive and become immune or die. Looking at this epi-curve, the disease detective could deduce a fair amount. A common source epidemic, such as bad potato salad at a picnic, would have a sudden onset, sharp peak, and rapid resolution among a limited population, whereas an ongoing problem such as a contaminated water supply might affect an entire community for a longer time. Once a likely moment of exposure was determined, i.e., the time of the picnic, the epi-curve also revealed the average incubation period, the time between infection and disease onset.

Tiny Parasites, Unwilling Hosts
Fossilized bacteria have been found in rocks over 3 billion years old. These single-cell organisms reproduce by dividing by fission—often in less than twenty minutes. Some bacteria are helpful, such as those that help us digest food, while others release chemicals that poison our tissues. To fight off infections, our bodies developed an elaborate immune system that creates specific antibodies for specific microbes. There are about two thousand known species of bacteria.

Also ancient, a virus is a protein shell surrounding a strand of nucleic acid, either DNA or RNA. It cannot reproduce on its own but must invade a living cell, which it takes over, commanding the cell to reproduce the virus at an incredible rate. There are about fifteen hundred known viruses.

Then there are the one-celled parasites, such as those that cause malaria, whose vector (delivery system) is the mosquito; larger bacteria called Rickettsia, usually inserted into humans by ticks or fleas; and fungi whose spores float from the air into the lungs or onto preexisting skin lesions. There are also chemical toxins produced by bacteria and other quick-acting poisons that, while not infectious, can kill people.

Microbes have evolved mechanisms to proliferate—for example, measles and influenza victims cough, spraying virus into the air; Shigella causes diarrhea in order to spread bacteria. Man against microbes is a fight for survival.

The Hazards of Improved Sanitation
Langmuir’s epidemiological techniques led to two important discoveries even before the creation of the EIS. When he arrived at the CDC, a $7 million budget was still devoted to fighting malaria because Southern doctors continued to report thousands of malaria cases when there was no other obvious cause of the fever. Langmuir’s first surveillance effort sent out teams to conduct surveys about the frequency of attacks, symptoms, treatment, and patient travels, and to collect blood samples. Investigations unearthed only nineteen positive cases of indigenous malaria and these were not in the significant clusters that would indicate a potential epidemic. Malaria had been virtually eliminated from the United States, but no one in the medical field had realized it.

In 1950 Langmuir sent twenty-six-year-old Ira Myers, one of the few doctors he was able to recruit before the “doctor draft” of 1951, to Charleston, West Virginia, to determine if flies transmitted polio¬myelitis, the viral crippler that terrified postwar America. Myers discovered that there was a much higher rate of paralytic polio in upscale ¬Kanawha City, a suburb of Charleston, West Virginia, than in ¬Chandler Branch, a poor area where cesspools dumped into the drinking water supply. By the time they were six months old, most babies in Chandler Branch had developed mild infections and were immune to polio. Poor sanitation had provided the Chandler Branch children with a surprising advantage over the kids in the more sanitary Kanawha City.

Meet the Author

MARK PENDERGRAST is the author of four other nonfiction books: Mirror Mirror, Uncommon Grounds, Victims of Memory, and For God, Country & Coca-Cola.

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