Medical detectives from Atlanta: the curious image of epidemiology at the Centers for Disease Control, January 26, 1995

Moderator: University of Iowa History of Medicine Society. Thursday, January 26, 1995. This evening’s speaker is Dr. Paul Greenough who is a professor in the University of Iowa Department of History. Dr. Greenough’s topic this evening is Medical Detectives from Atlanta, the Curious Image of Epidemiology at the Centers for Disease Control. Dr. Paul Greenough: Some people are turned on by the idea of cholera. Moderator: Paul, let me get the door here before you start. Dr. Paul Greenough: There is a handout. I guess there are enough of them because I see they're in the front row on both sides, so that's good. I want to talk tonight about medical detectives, about how the concept of the medical detective, or sometimes the disease detective came to be associated with the emerging profession of field epidemiology as practiced at the Centers for Disease Control and Prevention in Atlanta. Of course, it's possible that you may not be aware of this association, but if you read the daily newspapers, if you read weekly news magazines, or if you've been a faithful reader of the New Yorker over the last 20 or 30 years, you’ll know that various kinds of detectives in the CDC are regularly linked in popular journalism. Indeed, the terms disease detective and medical detective are journalistic tags. No one at CDC lays claim to them as his or her title. As we’ll be seeing, it is something of a parody to describe the work of the epidemiologist as detective work, and no other newly emerging health profession except perhaps psychiatry has seen itself so widely parodied in the popular press. The proper term for people who regularly investigate epidemic outbreaks is field or applied epidemiologist, and it's my interest in the practice of applied epidemiology at CDC by members of its Epidemic Intelligence Service, the EIS, that leads me tonight to reflect on the medical detective. Let me back up for a moment to situate this problem. Epidemiology is a new specialty in the health sciences. Epidemiologists are generally trained in universities, and like other established specialties in the health professions, epidemiologists are tribally divided between their academic and their non-academic applied practitioners. It is the latter I am considering, in particular those employed by the federal government as officers in the Public Health Service. In the history of modern professions, one can point to definite moments when professional privileges and practices become stabilized, there are legislative moments when the state recognizes a profession’s claim to technical expertise and agrees to grant it a major role in the selection and the licensing of qualified practitioners. Similarly, there are disciplinary moments when universities open specialized courses of instruction, the completion of which comes to be considered the normal route into the profession. There are also ethical moments when written codes of conduct find favor, usually accompanied by procedures for removing mal-practitioners and renegades, thereby warding off external regulation. Of course, the formalization of training and licensing and ethical standards, and internal policing are always intensely political projects, and a glance at the professionalization of medicine in this country shows just how much strife can be generated along the way. I had occasion recently to reread Paul Starr’s book called The Social Transformation of American Medicine, and was really struck again by just what an incredibly political project that it was over the last hundred years. Associated with the process of professionalization is the shaping and public projection of the image of the representative practitioner. I’m not talking about the crystallization of status rank, although that's certainly an interesting subject, I’m referring to the way in which the specific traits are braided together to form the image, the stereotype, if you will, of members of the profession. This image is an important adjunct of professional status. Consider the popular image of the modern physician, which combines some of the attributes of the traditional medical healer with those of the lab scientist in what is a very odd amalgam. On the one hand, the ethical values of the healer are self-consciously traced back along a golden stream of European practitioners all the way to Hippocrates. On the other hand, the aura of the scientist, one who traffics in new discoveries is symbolized by the laboratorian’s white coat, implies the constant refurbishing of therapeutics with all that is novel and Promethean. I’m almost inclined to ask Dr. McKinney to stand up and exhibit the characteristic garb. He’s sitting in the back in his white coat and his stethoscope around his neck. Now, both these elements of the physician’s image seem fanciful if we lower our gaze somewhat and look at real doctors in real practice. The ethical terrain of present-day medicine is fundamentally alien to that of a few thousand slave-owning citizen farmers of the 5th century BC, while most physicians today admit to staggering beneath a tidal wave of medical research that pours out of 100 or more universities like our own. Where did this double and doubly-misleading popular image of the physician come from? I won’t try to answer this question, but I will point out the obvious fact that that image has altered considerably over the last 40 years. Specifically, a third strand that once supported the image of the physician as the intimate advisor and friend of the family or the family physician, that third strand has long since frayed and has now nearly snapped. In this case, it was physicians themselves, by refusing house calls and moving massively into specialty practice, who willingly undermined one part of their own image. Thus, whatever complicated social communication process determines how various perceptions fuse to form a professional image, it's clear that the result is at least partly a matter of conscious choice. The image of the epidemiologist can be discussed in similar fashion as an historical construction that is partly the result of deliberate efforts to shape the popular perception of the ideal professional, and partly the consequence of day-to-day practices that wear away at that perception. So, there’s a process of trying to build up an image of what the professional epidemiologist is, and then there are certain practices that tend to erode it. So, this construction of the epidemiologist is a constant process. What have been the conscious elements in the representation of the epidemiologist? During the early years of the First World War, H. Winslow Hill, who was Director of the Division of Epidemiology for the Minnesota Board of Health, proposed a comparison between the epidemiologist and a professional wolf hunter. This startling image was employed, according to the historians Fee and Porter, at a moment in the evolution of the U.S. public health when an older sanitary idea that required engineering of the urban environment by cleaning the streets and purifying the water and so on, this older image of engineering and sanitation was giving way to new bacteriological methods that promised greater specificity in halting the spread of disease and at a lower cost. According to Fee and Porter, and here I’m quoting them, “Hill likened the epidemiologist to a hunter trying to find a sheep-killing wolf. The old-fashioned amateur hunter covered the mountain with his assistants, and told them to follow all the wolf trails until they found the one that led to the slaughtered sheep. The new professional hunter, however, took a different approach. Instead of finding in the mountains and following inward from them 500 different wolf trails, 499 of which must necessarily be wrong, the experienced hunter goes directly to the slaughtered sheep, finding there and following outwards thence the only right trail, the one trail that is necessarily and inevitably the trail of the one actually guilty wolf.” This is this idea that Hill had come up with. This is the image that he was trying to create. Now, in practical terms what Hill was talking about was the substitution of the culturing, the bacteriological culturing of pathogens isolated from an ill patient and substituting that for the engineering feats of purifying all the water in the city or carrying off all the garbage or removing all the sewage. Now, this image of the wolf hunter did not succeed. It was not accepted into general popular discourse, and epidemiologists themselves, I think, reacted with a certain amount of horror to the idea that they were wolf hunters. Hill got carried away with his own imagery. There probably are a number of other attempts along the way, and a few of them have begun to figure it out, but I want to move forward to talk about the main subject tonight, which is the CDC. In some early work that I’ve been doing, I’m writing the history of an organization within the CDC called the Epidemic Intelligence Service, and have established in some earlier chapters of this book that at the height of the Korean War, in 1951 in Atlanta, 21 Public Health Service physicians were assembled for field epidemiological training for the first time. And this group was expediently called the Epidemic Intelligence Service, a strange name, to take advantage of fears that enemy aircraft or saboteurs might launch biological warfare attacks against the United States. The primary task of EIS was to monitor unusual disease occurrences as an aspect of the nation’s civil defense. A secondary function was to offer help with epidemic outbreaks when requested to do so by state and local health officials. And, thirdly, the EIS was to conduct basic research in the nature and the spread of epidemic diseases. Now, the key figure in the EIS organization, until his retirement in 1971, was Alexander Langmuir, a physician and former Johns Hopkins epidemiologist who had joined CDC in 1949. If we can have the first slide, we’ll see a picture of Langmuir. It's going to be that, yeah. Langmuir mostly relied on the national doctor draft to fill up the ranks of the EIS. After 1975, when the doctor draft ended, aggressive recruiting and the reputation of the CDC in public health and scientific circles continued to draw well-qualified applicants who served two-year terms. To date, nearly 2,000 officers have passed through the EIS epidemiology training program, and then after their service fanning out into the universities, into state and federal public health departments, and into private practice of various kinds. And we have a number of former EIS officers on the faculty of the medical school here. Applied or field epidemiology, the epidemiology of outbreak investigations of disease surveillance and of the active anticipation of health hazards has had a speeded up existence at CDC. It's fair to say that there was no professional field epidemiology in the country before 1951, and then what I’ve called the legislative and disciplinary and ethical moments as outlined above occurred all at once with the creation of the EIS. As a federally authorized in-service training program created during a national emergency by the PHS, EIS practitioners were subject to the privileges and the restraints of uniformed officers in the service. In addition, because more than 90% of all EIS officers have been physicians, many of the professional norms of medicine were directly incorporated. Now, it's clear that Alex Langmuir began to worry about a certain question, the question of the professional image of his field epidemiologist early before the EIS was even two years old. He had to worry about this because there was a very practical reason. Any organization that's established during a wartime crisis might logically be disbanded once the crisis had passed. The crisis here being the Korean War and the expectation that the Russians might try a BW event in the United States. Thus, while continuing to assert that the EIS was necessary to defend the country against bacteriological warfare, Langmuir began to argue within the PHS that the EIS, the Epidemic Intelligence Service’s most essential function was to offer epidemic aid to beleaguered state and local health departments. He took this work seriously, making a fetish of rapid responses to state and local appeals, often getting an EIS officer to the scene of an outbreak within 24 hours of the first phone call. Doesn’t sound like the federal government. This activity soon came to the attention of the national press, which Langmuir then began to court. And it was at this time, perhaps late 1952 or early 1953, that Langmuir began to describe his officers in public as disease detectives rather than as field epidemiologists. Few outside the public health community would have understood in any case what the term epidemiologist meant, whereas the notion of disease investigation as a kind of detective work had already been made familiar in a best-selling book called Plague On Us by Geddes Smith, which was first published in 1941. This was a best seller, it went through four editions. In Plague On Us, Smith had formally elaborated the similarities between an epidemic investigation and a homicide investigation. Evidently, his motive in doing this was to solve the science writer’s perennial problem, how to translate technical matters into familiar language or familiar idiom. Thus, in a chapter called Detective Work, which describes the PHS and local public health investigators in a typhoid epidemic between … various epidemics between 1914 and 1936, Geddes Smith had referred to the spread of disease as the investigation’s plot, he referred to the food and water consumed by stricken patients as suspects, and laboratory results were referred to as clues, making this sort of one-to-one clunky translation. Smith’s popularizing technique obviously worked for his book. As I said, it went through four editions between 1941 and 1948. As a result, Langmuir could draw, in 1952 and 1953, upon an already widespread identification of epidemic investigations with detective work in explaining to the public what the EIS did. On January 19th, 1953, nearly identical news stories appeared in Time and Newsweek, both headlined Disease Detectives. There we go, and that's Langmuir. And both giving glowing accounts of the first full year of EIS investigations. The Newsweek story began as follows, “In almost any large scale disease outbreak, Dr. Alex D. Langmuir of the United States Public Health Service manages to combine business with pleasure. The hundreds of serious epidemics in the nation each year give the 42-year old epidemiologist the reward of helping people in dire emergencies plus the excitement of unraveling a mystery. As Associate Professor of Epidemiology at Johns Hopkins School of Hygiene and Public Health, Langmuir had dreamed of commanding an elite team of young doctors who would rush to the scenes of puzzling epidemics and solve them in the great U.S. PHS tradition. The epidemic troubleshooters have investigated more than 200 disease outbreaks ranging from German measles, jaundice and polio, to rabies, typhoid, influenza, malaria, and encephalitis. Their expert sleuthing has turned up some neat Sherlock Holmes conclusions.” The Newsweek article then went on to give capsule accounts of several EIS investigations, and they were drolly labeled as the Case of the Camp Sewage, The Case of the Carrot Salad, The Case of the Korean Camper, The Case of the Culex Killer. As these tags suggest, EIS investigations at this time were principally confined to common source epidemics, that is outbreaks that occurred in a restricted social group after the members were exposed to a single noxious source of infection in a relatively brief period of time. And archetypally, these single-source epidemics, common source epidemics are talked about as church picnics with infected mayonnaise. This is the Newsweek story, and the other one was the Time story. The Time article was slightly more faithful than Newsweek to the details of a major investigation of 1952, one in which EIS officers succeeded in discovering the source of nine cases of malaria among 1,500 campfire girls who were camped at Lake Vera in the foothills of the Sierra Nevada in California. In Time’s breathy prose, the investigation developed as follows, “Mosquitoes trapped at Lake Vera prove to be of the disease-carrying kind, but who took the malaria there to begin with? For a while, the disease detectives seemed to be up against a blank wall. After almost a month, they got a break, the owner of a house near the camp asked a neighbor casually, “Wasn’t it too bad about the malaria at the camp?” “Yes,” was the answer, “but he’s all right now.” “He?” “Yes, my son. He got malaria in Korea and had a relapse while he was visiting up here.” As soon as this backyard chitchat was reported, the puzzle was solved. The Marine veteran of Korea got medical care and spread the disease no more. The Lake Vera area was sprayed to kill off the last infected mosquitoes. To the 32 disease detectives of the U.S. Public Health Service, the Lake Vera assignment was a little out of the ordinary.” Now, actually this last line in the Time’s story was not true, not only did the Lake Vera investigation demonstrate unusual tenacity, because all 1,500 campfire girls had dispersed from the camp to their homes all over California, and each had to be tracked down and questioned, but this investigation very much impressed the California State Department of Health, and a very close working relationship between CDC and the California health authorities was forged at that time. Now, these January 1953 stories in Time and Newsweek set the pattern for further reporting in the popular press. EIS investigators were thereafter regularly called disease detectives, for example, in The Saturday Evening Post, I hope I’ve got this right, right, in May of 1953, Medical Gum Shoes in Coronet magazine in August of 1956, Medicine’s FBI in the Reader’s Digest of May of 1959, or Sleuths from Atlanta in Parents magazine of October 1963, and so on and so on. This one is interesting because it's from JAMA, okay, at a slightly later date. What happened here in these stories is all the accounts are short and shallow, but the reporters were respectful of the EIS and they gave excellent publicity to the Public Health Service, which otherwise was very rarely in the limelight. But this was what I would call anemic sensationalism, because people read these things and they passed out of their imaginations quickly. Anemic sensationalism of the field epidemiologists might have gone forever except for the appearance, in 1965 in Atlanta, of Berton Roueché, a staff writer from the New Yorker, who had a unique forum, a column called The Annals of Medicine, which ran periodically in the New Yorker from the 1940s to the 1980s. Now, Roueché was not a hack, but a skilled fiction writer. There he is. He was a skilled fiction writer who had written novels and other full-length studies in a career which began under Harold Ross, the legendary founder of the New Yorker. At Ross’ suggestion, Roueché began, in the early 1940s, to write up unusual episodes drawn from the files of the New York City Health Department, episodes of what he called Medical Detection. One of the first, and perhaps the most widely known of these stories, is Eleven Blue Men, which is a classic of a common source epidemic. By his own account, however, Roueché began to run out of suitable material from New York in the 1960s, and this is when he discovered the Centers for Disease Control. It was he more than anyone else who brought depth and moral purpose and, above all, glamor and excitement to the image of the epidemiologist. The Newsweekly writers had been content to use the term medical detective simply as a label, but Roueché put the vigorous methods and the logico-deductive skills of the classical detective at the center of his characterizations. As might be anticipated, Roueché and Langmuir developed an informal alliance. Roueché was given access to summary reports of EIS investigations from which he selected the few cases that met his requirements. In return, the CDC and applied epidemiology received striking publicity in one of the most influential journals in American life. It's influential if you grant that sway over a market base of literally intellectuals and Manhattophiles and high income professional constitutes influence. Some people would doubt that the reader base is influential. With Langmuir’s encouragement, a handful of EIS officers spent hours explaining the minutest details of their investigations to Roueché, who took copious notes, and then he went away, wrote up his drafts and shared them with the CDC protagonists for accuracy. And out of this painstaking process came a series of remarkable stories first appearing in the New Yorker, and later collected into hardcover and paperback editions for a mass market, and they were translated into many other European languages and Japanese. In 1967, a number of these stories, along with some of Roueché’s earlier New York tales in Medical Detection, were published in a collection called The Annals of Epidemiology, which is still available in paperback, and it's good reading, so I recommend it to you. Not surprisingly, the introduction to The Annals of Epidemiology was written by Alex Langmuir, who observed, “Mr. Roueché writes with a happy combination of the discriminating judgment of the skilled diagnostician, a passion for accuracy of the trained news reporter, and the narrative skill of the detective story writer, and the perspective of the historical scholar.” No praise is too great for Roueché from Langmuir, obviously. “The high esteem he enjoys among those about whom he’s written serves as a testament to the authenticity of his writing.” What are these stories of Medical Detection like? They are always based upon actual events, and each story is focused on a single disease. While not fictions, they are shaped by the conventions of the classic mystery tale in which disease replaces crime, and the search for the offending pathogen or for the source of an infection replaces the hunt for a criminal. The medical investigator, usually a physician or a physician epidemiologist, is cast as an energetic and insightful sleuth who is often seen assisting a helpless victim for whom we’ve developed some sympathy. The data the epidemiologist collects are given to the reader one by one as clues in the same sequence in which they’re discovered by the investigator. A sense of crisis hangs over the narrative because the patient may worsen or the disease may spread. Suspense is prolonged in most stories by a digression in which Roueché gives the reader enough historical and technical background to appreciate the threat of the disease which is under scrutiny. Sometimes, the plot requires the investigator to ward off the interference from other professionals or to cope with their bungling. Even when, as sometimes happen, the patient dies, Roueché’s stories always end with a favorable resolution of the medical and the epidemiological issues. I interviewed Berton Roueché in March of 1985, and he willingly informed me that he models his stories directly on the Sherlock Holmes tales of Arthur Conan Doyle. He told me, “My requirements for material are that I want a story of an investigation that is complicated, that has blind alleys and red herrings, and with a denouement that is surprising. So, first of all, the investigation has to be successful. These investigators are all heroes, they’re winners. An investigation that doesn’t get anywhere wouldn’t suit my purposes, my sense of dramatic structure comes from Sherlock Holmes.” Now, in terms of the Arthur Conan Doyle archetype, the EIS officers regularly play the role of Sherlock Holmes. The role of Inspector Lestrade of Scotland Yard, and there are a few in this room I know who relish the details of this interaction between Sherlock Holmes and Inspector Lestrade, this role of Inspector Lestrade whose narrow outlook and doubting attitude Doyle always satirized appears as the bungler who has missed the diagnostic or epidemiologic clues lying at his feet. And the worshipful role of Dr. Watson is taken by the narrator himself, that is by Berton Roueché. Elsewhere, Roueché has written, and here I quote him again, “I attempt to illuminate the method involved in the scientific investigation of epidemic disease. My approach is different from the dry accounts published in public health journals. It is chronological and comprehensive. I reconstruct the investigation as it was actually carried out. I include the flounderings up blind alleys, and the stumbles down garden paths, but I withhold the source of the trouble as it was withheld from the investigator himself until it is discovered by the evidence. If the form of the narrative seems to resemble that of a classic detective story, it should be remembered that Sir Arthur Conan Doyle derived the Holmesian method from the great Edinburgh diagnostician Sir Joseph Bell”, which is true, this is absolutely the case. As can be seen, Roueché asserts that his stories recreate the experiential world of both the diagnostician and the epidemiologist. Indeed, he is as likely to write about diagnostic problems as epidemiological ones, and it is presumably this dual subject matter that causes him to label his protagonist medical detectives rather than disease detectives. Remember, Langmuir began using the term disease detectives, but in the gloss of Roueché they’re medical detectives, they diagnose. Now, ordinarily, a historian would not pay too much attention to such stories as the source of information, but there are reasons to take Roueché seriously. I’ve already said that he has spread the Sherlockian image of the implied epidemiologist far and wide. In fact, there is more said about field epidemiology and about EIS officers in Roueché’s stories than can be found in all the other published accounts of the EIS put together. Yet, to my knowledge, no one has ever questioned or elaborated Roueché’s image of the medical detective on the basis of a familiarity with what epidemiologists do and are. Beyond the fact that everyone at CDC seemed content until very recently, Roueché died in 1994, seems content to let Roueché speak in public for the EIS, there is the curious fact that Roueché’s stories have actually been used to recruit and train physician epidemiologists. The American Public Health Association, for example, noted in 1985 that his stories are “Unofficial text in medical schools and for health professionals in general”. And this is the case, I make a point of inquiring, and I find that this collection of stories called Eleven Blue Men is very widely used at some level in medical training around the country. I don't know if that's the case here, maybe we’ll find out during discussion. Roueché confirmed that his books sell well in health science bookstores. In a survey that I conducted of present and past EIS officers, a dozen out of approximately 700 respondents indicated that Roueché’s New Yorker stories had attracted them to medicine in general and epidemiology in particular. Langmuir was well aware of the recruiting potential of these stories, and in his introduction to The Annals of Epidemiology, this thing, he says, “Those who choose to read and reread the writings of Roueché with the same thoughtful concentration with which he has prepared them will take a major step toward an understanding of the epidemiologic method, and hopefully may be encouraged to consider epidemiology as a career”. So, this is very much on Langmuir’s mind this is a way to snag talented physicians into the EIS. Notice also that Berton Roueché is the only non-epidemiologist ever invited to join the prestigious American Epidemiological Society, it's the sort of pinnacle organization of American epidemiologists. Clearly, Roueché has not only affected the reading public’s perception of epidemiological practice, he has also deeply impressed epidemiologists themselves with a captivating vision, a glamorous vision of what they do and who they are. It's time to look closely at … well, is it time to look closely? Yeah, I guess it is, to look closely at a Roueché story. Of the 10 tales that he has written to date, and he stopped writing them in the early eighties. There were 10 of them all together. Of the 10 tales that he has written based on a CDC EIS investigation, I want to examine the second one he wrote. It was published in the New Yorker on April 25th, 1965, and is called A Man Called Hoffman. I choose it over others because it has most of the characteristic features in stark form and because it stars, as the sleuth, Phillip Brachman, MD, EIS Class of 1954. Brachman is the epidemiologist who replaced Alex Langmuir as the Head of the EIS in 1971, and he is widely known as a superb investigative epidemiologist. Now, I wanted to give you a kind of precis of this story called A Man Called Hoffman, but it's radically truncated. A 36-year old man, Donald Hoffman, a resident of Cincinnati was employed in March of 1964 as an insulation installer in Oxford, Ohio at a hospital construction site at Miami University. Hoffman developed a small sore on his neck, which he presumed to be irritation from a sliver of fiber glass, not unusual in his line of work. He was examined on a Wednesday morning by an MD in the Miami University Student Health Clinic. He had a small lesion and a temperature of 99 degrees plus. He was advised to have a penicillin injection, but he refused and returned to work, his attitude was nonchalant. On the same evening, when he was back home in Cincinnati, he came to a hospital with a temperature of 102 degrees with fever and aches, and the examining MD admitted him and gave a penicillin injection diagnosing abscess with cellulitis. The next day, Hoffman felt better, Thursday, but Thursday evening he went into shock and required resuscitation several times. Blood, plasma, and vasopressors were given. Swelling constricted his throat and he found it difficult to breathe. Oxygen was administered. His blood pressure wildly oscillated, and on Friday morning at 7:00 a.m. he died. So, Wednesday to Friday. The death report reported stated “septic shock due to abscess with cellulitis on the neck and anterior chest”. Four days later, a routine culture of Hoffman’s blood revealed anthrax bacteria. This was reported in due course to the Cincinnati Health Department whose assistant commissioner reported it to the CDC. The same assistant commissioner happened to be going to Atlanta the same day and brought the bacterial culture to Philip Brachman, the Chief of the CDC’s Investigations Section’s Epidemiology branch. Brachman is described in this story as an expert on anthrax, and he passed the sample to CDC labs which confirmed that the bacillus, the bacteria was anthrax. Now, at this point in the story, Roueché interrupts the narrative for a five-page digression on the history and the etiology of anthrax. We learn, first, that it's mostly a disease of animals, which are the major reservoir of infection, but that it can be conveyed to humans by very hardy spores that attach to animal hair and hides. Second, we learn that the disease is easily prevented by an effective animal vaccine, but that anthrax is, nonetheless, still common in underdeveloped nations. And, third, we learn that once someone is infected with anthrax bacteria, there’s no good treatment because the bacteria releases a deadly toxin, and even though antibiotics can kill this bacteria, the toxin works its way through the system and kills the patient in most cases. Now, resuming the narrative, we learn that Brachman’s next move is to put an Ohio-based EIS officer named Peter Greenwald on the case. Peter Greenwald learns that Hoffman was working with felt insulation and animal hair product. He also determines that this insulation was manufactured by a Chicago-based firm, which Roueché calls the Ajax Corporation, not its real name, and that it had been produced at this firm’s Milwaukee factory. He obtains the batch number of the suspect insulation from Hoffman’s boss. At this point, Philip Brachman takes over the investigation because he realizes that this felt product, with the bacteria probably in it, is in national distribution. Brachman first calls the firm’s Chicago office to alert them to his investigation. He then flies to Columbus, Ohio to confer with Peter Greenwald and Ohio health authorities. He drives with Greenwald to the hospital where Hoffman has died, and he interrogates the attending physician and the hospital bacteriologist. He also visits the construction site and the warehouse where Hoffman’s employer stores his insulation, and samples of the felt product are collected at both of these sites. Brachman then flies to Milwaukee to see the insulation manufacturing plant, only to discover when he gets there that the batch in question actually came from the firm’s New Jersey plant. So, he goes back to Chicago, he flies to New York, he takes a train to Newark, and he discovers that the Ajax Corporation keeps very good records, and he succeeds in collecting samples of the imported raw goat hair used in the felt manufacture, and he also takes a number of samples of other hair products which are in the warehouse. Brachman obtains these samples after an afternoon laboring inside the Ajax warehouse with his sleeves rolled up. It's messy, very messy work. After six days on the road, Brachman returns to Atlanta. He personally prepares each of his samples for bacterial culture. Out of 49 which are collected, 13 turn out to be positive for anthrax. These include the goat hair samples from the Newark warehouse, the insulation samples from the Cincinnati warehouse, and the samples from the Miami University work site. Thus, a trail of positive anthrax cultures link Hoffman to the imported source in Newark, QED. Well, it's a fine story. It's informative, and it's deeply satisfying even though I’ve stripped it of many of its details and local color. Why does this story, A Man Called Hoffman, work so well as an account of medical detection? And it really does work, really just to read through it you just slice through it like butter with a sense of satisfaction. First, notice the elements of pursuit and suspense, the segment and trail with its false lead to Milwaukee, the uncertainty until the end whether Brachman can prove a connection between imported goat hair and Hoffman’s death, the threat that the Ajax felt hair insulation will cause an outbreak elsewhere. Second, notice Brachman’s energy, his ability to rise early and travel late, his willingness to get himself dirty if need be, and to perform the laboratory tests himself. Brachman is out and moving about, while the others, the attending physicians, the bacteriologists, and even Peter Greenwald, they’re confined. Brachman literally flies about the country and his chase takes him into unlikely places, Ohio work sites and New Jersey warehouses, but the logic of his visits to these places is never faulty. There are no physical constraints on his activity, his authority flows ahead of him and costs are never an issue. Then, notice the autonomy he enjoys, how he keeps all the strings of the investigation, the site visits, the contacts with state health authorities and Ajax officials, the lab work, he keeps it all in his own hands. Related to this is his reluctance to accept anybody else’s data without checking them, and Roueché quotes him as saying, “I had to see it all and touch it all to get a feel for the case.” Those are some of the reasons, I think, why this story worked so very well, we recognize the archetype, the Sherlock Holmes underneath it. Now, it must be obvious that I have some problems with all of this. Not with the story, it's a wonderful story, but with its adequacy as an account of the reality and the significance of an epidemiological investigation. And let me suggest where I would quarrel with Roueché, approaching this as a historian. In the first place, the precise nature of Philip Brachman’s professional interest in anthrax is not explained. Roueché quotes Brachman as follows, “Anthrax is something of a specialty of mine. That's a little these days like specializing in botulism or rabies or small pox. I mean it's an interest one doesn’t have much occasion to indulge, for which of course I’m grateful, but when a case does come along, I like to follow it up if I can.” This is quoting Brachman. Now, this quote suggests that anthrax was a kind of hobby for Philip Brachman, whereas the actual explanation is a little more grave. Since at least the 1950s, anthrax was being studied by the U.S. Army Chemical Corps as a biological warfare weapon. Anthrax is a plausible BW agent because the bacteria are easily grown in quantity, the victims are incapacitated by the toxin before their symptoms lead to the right diagnosis, and there is an effective vaccine to protect troops against the enemy’s anthrax weapons. The CDC was involved in several phases of this biological warfare research, especially in the valuation of the vaccine, and Brachman was the resident CDC anthrax expert. In the mid-1950s, he had been trained at the Wistar Institute in Philadelphia in appropriate techniques for culturing pathogens, and he had subsequently conducted extensive experiments on inhalation anthrax in monkeys. Before the Hoffman episode, he had investigated dozens of cases of anthrax in human beings, trying to answer crucial technical questions. For example, what is the epidemiology of the disease in man, and how large a dose of the bacteria does it take to initiate an infection? The Army wanted to know. The Hoffman case was added to Brachman’s file of hundreds of spontaneous outbreaks, and at the end of the investigation he sent a copy of his report along with slides prepared from Hoffman’s lesion to the biological laboratories of the Army Chemical Corps at Fort Detrick, Maryland. That information is not in the story. Second, A Man Called Hoffman hardly takes account of the fact that Brachman was a federal employee in a branch of the then Department of Health, Education, and Welfare. Brachman has a boss, it's Alex Langmuir, who in turn was subordinate to the Director of the CDC, and so on up the chain of command to the Surgeon General of the United States, who happens to work for the President. Only in the closing paragraphs of his story does Roueché mention that an ad hoc committee was convened by the PHS in Washington in May of 1964 to decide what to do about the threat from the rest of the Ajax Corporation’s insulation which had been widely distributed throughout the United States. In this passage at the very end of the story, Roueché reinforces the notion that Brachman stands in radical isolation from the rest of the PHS bureaucracy. He has Brachman heaving a sigh of relief that policy meetings and deliberations were the responsibility of other people. And one can easily see that such an attitude is defensible in fiction. After all, we don’t expect Sherlock Holmes to attend a conference called by Scotland Yard in the aftermath of the Baskervilles adventure to write leash laws for wild mastiff hounds. Yet Brachman’s own file on the Hoffman case, the real file in the PHS archives, his own file make it clear that it was he who suggested the Washington meeting, it was he who drafted the agenda and nominated its participants, and it was he who led the committee step by step through the various policy options. In doing so, he was fulfilling the part of the CDC’s mission, which is to go beyond the resolution of a particular outbreak to anticipate where disease will next insult the public’s health. The elements of bureaucracy, institutional mission, political authority, and financial limitations are opaque in Roueché’s CDC stories, yet in life such elements hedge in all institutional protagonists, fixing their activity in a net of determination. Take the least of these factors, the matter of financial constraints. It's in Don Quixote where the noble knight remarks that, “A romance is a story in which no one ever explains how the hero pays for his accommodation.” And, remember, this is a dilemma for Don Quixote, how does he pay once he sets out on his tour? What will we make of the Hoffman story if we were told that Brachman drew cash advances in Atlanta only after completing forms with the appropriate signatures, that CDC travel rules required him to book the cheapest flights, and that he had to furnish the Public Health Service accounts with motel receipts when he returned to Atlanta from Newark? What would the reader think were he to learn that Brachman personally cultured for bacteria the 49 hair and insulation samples he had collected because the CDC could not free up the time of a staff bacteriologist? That's the reason which is in the record. I’m not arguing that historians should trip up Sherlock Holmes in paperwork and procedure, but I think it worth noting that the real world is one of accomplishments in spite of annoying financial restraints, bureaucratic routines, and delayed flights. It isn’t likely that in real life a silly carp like Inspector Lestrade, or a fiendish opponent like Moriarty will compromise a field investigation. It's more likely that the epidemic will simply resolve itself spontaneously, which happens very, very frequently, by the time the EIS officer gets there, or else the investigation will be aborted because the fiscal year ends in four days. Third, Roueché fails to draw attention to the ramified network of municipal, state, and federal public health officials that Brachman drew upon to launch his investigation. It isn’t important for the story to ask why the assistant health commissioner for Cincinnati thought to call Brachman in Atlanta, and why he carried a stoppered tube of anthrax culture in his shirt pocket to Brachman the same day, but such matters were vital for triggering the CDC’s participation, a very close working relationship there. Similarly, Roueché states but does not highlight the fact that Brachman was personally acquainted with Dr. Harold Decker, the Chief of the Communicable Disease Division of the Ohio Health Department, and thus had no protocol problem in entering the state. Brachman’s subordinate, Peter Greenwald, the EIS officer, had in fact been stationed in Columbus for nearly two years working with the health department before Hoffman fell ill. Even so, Brachman’s records indicate that, in addition to getting permission from state and municipal health officers, he sought and obtained clearances for his investigation from three county health commissioners, four attending physicians, and the hospital administrator where Hoffman died. Thus, Ohio was permeable to Brachman’s investigation as a result of his carefully nurtured personal relations with state and local officials and his conscious practice of acknowledging others’ spheres of authority. Now, why am I harping on this? Because, constitutionally speaking, health matters in the United States are reserved to the states. Federal agents require permission to visit the site of an outbreak, and to interview attending physicians, and to review hospital medical records, let alone to take away samples for biological tests in Atlanta. The CDC epidemiologist who responds to a state’s call for epidemic aid is crossing a threshold in the federal system. Apart from political hazards to be negotiated, there are professional sensitivities to be attended to. A state or local health official, for example, cannot help but feel ambivalent about summoning a federal agent, for the summons is a confession of incapacity and need. Notice that when a federal epidemiologist takes part in a local epidemic investigation, he or she acquires an interest in any publication that may result. In epidemiology, as in surgery or internal medicine, the publication of a striking investigation enhances one’s career, and the stage is set for a tug of war between EIS officers and local officials over priority of publication. Well aware of the problems that could develop, CDC has elaborated a protocol, it was elaborated long before Hoffman. This protocol channels all requests for permissions to investigate, to collect data, to offer advice, and to disseminate results through the state health department. And when this case was actually published in the Morbidity and Mortality Weekly Report in April of 1964, it was published over the name only of the Ohio public health officials, and Brachman’s name was not attached to it at all. This is a conscious decision that the MMWR, the federal official’s names do not appear, only the local’s, and this is to foster the close working relationship. However, even such conscientious practices sometimes fail to overcome all tension, and there are large populous states in the U.S. which keep and have kept CDC epidemiologists out for decades because of personal and professional differences between the state and federal officials. In several respects, then, modeling the contemporary American field epidemiologist on a Victorian fictional prototype, on Sherlock Holmes, a bold and tenacious amateur who is unnaturally vigorous and observant, privileged and socially aloof, intellectually and financially independent, condescending to the established forces of law and order, this has produced a parody in Roueché. The drawbacks of this parody accrue not to Roueché, who succeeds brilliantly in shaping his material to the canons of a well-known and much-loved antecedent, nor to Brachman, whose approach to and disposition of a threatening disease outbreak was flawless, the drawbacks accrue to the profession that knowingly has accepted this image, this Victorian image of who and what they are as good enough representation of what its members do. In the short run, no doubt, that is in the 1960s and the 1970s, only good feeling and good press resulted from this parodic account of the federal medical detective. But in the present, when so much of CDC’s epidemiology involves sleuthing with computers through vast deposits of environmental, behavioral, and surveillance data to identify complexly-related and often low level risk factors, the Sherlockian image seems more and more irrelevant. Epidemic outbreaks still occur and are still run to ground by solitary investigators in the field, but new technology has begun to change the understanding of what constitutes an epidemic and to alter epidemiological practice. The regulatory and forensic climate in which epidemiology proceeds has radically changed. Nonetheless, the Sherlockian image of the intrepid and self-sufficient epidemiologist continues to appeal, and Roueché’s success has spawned imitators who show less seriousness of purpose. Now, this chap, I don’t want to say a lot about. His name is [Gerald Astor 00:50:52], and he decided to take up the medical detective when Roueché stopped writing it. And he has a collection of 10 stories, and he had interviews and access, as Roueché did, to CDC records and personnel. They’re awful stories, they have none of the class of a Roueché story. But I just wanted you to know that people were struck by the possibilities and this imitation is up out of there. But this is not the person I want to talk about. It was only a matter of time until another kind of writer, sensationalistic and more responsive to the market for thrillers appeared. In 1987, Robin Cook’s novel, Outbreak, appeared. There it is, Outbreak. By the way, Robin Cook has a new best seller. It's in the windows of Prairie Lights in Iowa Book and Supply. Every two years he comes out with a medical thriller. So, this is the one from 1987 called Outbreak. Now, let me tell you briefly about this. In this novel, Outbreak, it's a genetically engineered fiction, okay? It's created by inserting the sleuth DNA from a Roueché story into the genome of a paranoid plot by Robert Ludlum. Okay? Okay. In brief, Outbreak concerns an EIS officer named Marissa Blumenthal who discovers that a right wing physician’s group called the Physicians Action Congress has stolen Ebola hemorrhagic fever virus from CDC’s highest security virus containment facility, in order to plant this virus of Ebola on the premises of a health maintenance organization owned by foreign-trained physicians. You get it? This is serious stuff. Blumenthal investigates several of these planted epidemics before confirming her suspicions, but she cannot convince her CDC bosses, and in the meantime her adversaries are tipped off and make half a dozen attempts on her life from coast to coast. I mean they try to choke her in an airplane, and they try to throw her down a stairwell, and so on and so forth. Now, much of the irony of Cook’s characterization lies in Blumenthal’s violation of the Sherlockian persona. She is described as a beautiful, romantic woman, brilliant, five feet tall, and terribly naïve. Nonetheless, she outwits the hired thugs and the evil doctors and sees them jailed at the novel’s end. And in the final pages, the same CDC officials who had been furious with her for various acts of insubordination forgive all and her handsome virologist supervisor falls in love with her. I almost said virile virologist supervisor falls in love with her. In short, Outbreak is highly readable trash. Now, significantly, Robin Cook works into his novel many of the elements that Roueché routinely leaves out, things like personal relationships, politics and violence, detailed descriptions of how wealthy people live or allegedly live and dress. Surprisingly, however, Cook reveals a much more informed knowledge than Roueché of the Centers for Disease Control. For example, Cook has in hand the facts of the administrative organization and bureaucratic hierarchy. He places Marissa Blumenthal, his heroine, precisely in the Special Pathogens Branch of the Division of Virology within the Centers for Infectious Diseases, one of the constituent units of the CDC. Much of the plot turns upon Cook’s description of the CDC’s physical plant in Atlanta and of the security procedures limiting access to the virus containment facility. This is all described with great detail in the novel. Further, Cook writes knowledgeably about the complications that actually accompany an epidemic investigation. The EIS officers need to be invited officially by the state epidemiologist, it's in the novel. The field epidemiologist dilemma, facing journalists before an investigation is actually concluded, it's in the novel. The marked ambivalence of local health professionals at the arrival of a young federal officer, that's in the novel, too. The need to stay in touch with superiors in Atlanta by telephone, it's there, et cetera, et cetera, et cetera. In all of these matters and many more, Cook shows accurate knowledge and insight with a paradoxical result that a truly stupid plot is embedded in a realistically detailed physical administrative and professional infrastructure. This, too, is an inversion of a Roueché story but no truer to life. Okay? I think I’ll just stop there. I’ve talked long enough, so we’ll just let you … I think you gather my major points. I don’t need to hammer them away, so. Moderator: Thank you very much, Paul, for a very entertaining talk that was very [thorough 00:56:01]. We want to take a little time afterwards for questions and a little discussion, so I’m sure Paul would be happy to entertain questions right now. Dr. Paul Greenough: Sure. Speaker 2: How does the professional view of that epidemiologist compare with different [countries 00:56:18] in Europe? Dr. Paul Greenough: Europe doesn’t have very much in the way of field epidemiology. In fact, one of the interesting thing that's happened is that this EIS kind of service, where you take people who are mostly trained as doctors, and you give them, in effect, a-