Inside the Outbreaks: A book review

This is the first and almost surely the last time I will use this space for a book review, but because the author, Mark Pendergrast, was kind enough to send me a pre-publication copy for review, I willingly do so.

Inside the Outbreaks is the long-awaited history of the Epidemic Intelligence Service (EIS), which has grown during the last half century from a small and intrepid band of young aspiring physician-epidemiologists seeking to avoid the military draft in 1951, to a much larger group of rather more sophisticated individuals from a variety of health disciplines, many of whom are there because of career interests in global public health.

In the book, the 60-year span of the EIS is divided into three large sections.

The first section, titled “The Grand Adventures of Dr. Langmuir’s Boys,” extends from 1951 to 1970 and covers the period of Langmuir’s personal direction of the program. It was a free-wheeling era (in which I was privileged to participate), for the new EIS program was still well under the radar of levels of government above the CDC director’s office.

The second section, titled “The Golden Age of Epi,” extends from 1970 to 1982. This is an era in which a number of nationally prominent outbreaks (eg, Legionnaires’ disease and toxic shock syndrome) were studied and eventually solved. During this era, the EIS program began to achieve professional, political and public recognition; this proved to be a mixed blessing at best. The author never explained why he considered this the “golden age” of epidemiology.

Finally, the last section extends from 1982 to the present and is titled, simply, “Complex Challenges.” There is no need to explain that title further.

Anyone expecting to read a series of medical mysteries, artfully woven together in the style of Berton Roueché is doomed for disappointment; this book is not that at all, nor could it possibly be. It is, rather, a series of mini-vignettes about the nature of the outbreaks that EIS officers worked up. The book succeeds admirably in giving the reader a picture of the enormous variety of epidemiologic problems referred to the EIS, from infections to intoxications, infestations to clusters of malignancies, environmental issues to frank criminal activity. It fails, however, to convey much of the sense of drama that was inherent in most of the outbreaks described.

Another downside is that the reader does not become acquainted with any of the active-duty EIS officers or even the mid-level administrators such as D.A. Henderson, Phil Brachman, Carl Tyler and others. The only person the reader gets to know — even a little bit — is Alex Langmuir. Nonetheless, the portrayal of Langmuir seems accurate enough — proud, egotistical, committed to field epidemiology, a superb and demanding teacher. There are not just a few EIS alumni from the Langmuir era who will claim that the quality of the science coming from the EIS program has never again been as strong as it was during the Langmuir era.

Writing up an EIS investigation for publication under Langmuir, regardless of whether his name was to be on it or not, was an exercise in frustration, to be sure, but it was a learning experience like no other. I went through this exercise several times with Alex and was glad to have had that experience. Once, after an influenza-related visit to the Tommy Francis/Fred Davenport laboratories in Ann Arbor, Mich., I suggested in my report that they appeared to be occasionally guilty of “armchair immunology,” just as EIS officers were sometimes accused of “armchair epidemiology.” Alex laughed heartily at that language.

Political influence on science

The author brings out the political influences on CDC and the EIS program in areas that were relevant.

These grew distressingly more frequent in recent years, especially in the last decade. The Bush II administration, for example, was cited as perhaps the first time that politics trumped science, especially in the efforts to prevent transmission of HIV. The inability to use federal funds to promote condom use was a huge defect in the otherwise laudable President’s Emergency Plan for AIDS Relief (PEPFAR) effort.

Epidemiologic studies of gun violence would surely represent another “natural” for study by the EIS. For well over a decade there has been in place a congressional prohibition on the conduct of such studies; it’s almost as if the second amendment forbade even the study of gun violence. This was a political influence of which I had been unaware; I suspect the fine hand of the NRA had something to do with this, also.

Pendergrast also sometimes used harsh words to describe the Gerberding era as CDC director. The first misstep, in his view, was the introduction of a whole new layer of bureaucracy between the director and the program leadership. A number of well-known senior scientist-administrators left CDC in protest when that happened. This situation was immediately rectified when Dr. Frieden took office as the new CDC director.

I recall stating in this space that the “mask vs. N-95 respirator” flap in pandemic H1N1 infection was the first time I was aware that politics trumped science in CDC recommendations; this may still be true in the area of health care-associated infections, but evidently not in other areas more sensitive to political manipulation, such as HIV/AIDS.

Whom will this book appeal to? I would expect that most EIS alumni will pony up and buy it.

I suspect further that some will be disappointed at the seemingly limited sense of drama in the book. It likely will appeal to non-EIS infectious disease physicians as well. The appeal to other physicians will be limited. It probably will do better among people who have worked in health care in the past.

All that said, I found it to be an enjoyable read, and would recommend it to anyone contemplating a career in public health in our global village.

Next month, I will return to more typical fare.

For more information:

• Pendergrast M. Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service. 1st ed. New York: Houghton Mifflin Harcourt; 2010.

Author response

by Mark Pendergrast

I appreciate Dr. Eickhoff taking the time to review Inside the Outbreaks, my history of the Epidemic Intelligence Service, and his observation that the book “succeeds admirably in giving the reader a picture of the enormous variety of epidemiologic problems referred to the EIS.” But I would like to address several of his other comments.

I am a great admirer of the late Berton Roueche’s work, but Roueche’s lengthy, discursive style of writing about one outbreak investigation could not have worked in a comprehensive history of the EIS. Instead, I had to cover a wide array of investigations much more quickly.

I strongly disagree, however, that the book fails to convey a sense of drama during the investigations. The title of the book is accurate in that it takes readers “inside” the investigations from the point of view of the EIS officers who were on the ground, urgently trying to figure out what was causing disease and death. I am particularly proud of the coverage of such major subjects as AIDS, toxic shock syndrome, Reye syndrome, L-tryptophan, West Nile virus and the anthrax letters. There is no room here to quote from the book, so readers will have to judge for themselves.

Eickhoff laments that “the reader does not really become acquainted with any of the active duty EIS officers.” That is often the case. I had to cut the book manuscript nearly in half for Houghton Mifflin Harcourt, and I had to cut much of the personal background of officers. (The uncut version is housed at the Emory University archives and will be available online from Emory in April 2011.) Even so, I did include some personal material, quoting from contemporary letters back to spouses or Kent Campbell’s wife thinking he would die of Lassa fever.

Eickhoff observes that I did not explain why I called the second section in the book, covering 1970-1982, the “Golden Age of Epi.” It was a period in which the epidemiology became fairly sophisticated, major new diseases were identified, and smallpox was eradicated. Maybe I should have called it the “Heroic Age” instead of golden.

At the end of his review, Eickhoff suggests that the book will not appeal to non-ID physicians. I believe he is wrong in this assessment. While even the most seasoned EIS veteran will learn a few things from the book, it will serve primarily as an inspiring introduction to the EIS, field epidemiology, and the importance of well-funded public health efforts to students and the general public, most of whom have never heard of the EIS.

This book took me 5.5 years to research and write. It was a labor of love, and although the book is a “warts and all” history, there are few warts. I became personally involved in the story, as you can see from short video footage I took in Niger while following EIS officers there on a bednet surveillance project. If you have 3.5 minutes to spare, go to www.mark pendergrast.com and click on the YouTube link from the Inside the Outbreaks subpage. I hope to continue to write about public health issues for the rest of my writing career.

EIS officers and alums have had an effect far beyond their original numbers. Today, with global public health bedeviled by substantial threats, the life-saving work performed around the world by these shoeleather epidemiologists is more essential than ever. The EIS program and its offspring have, in short, influenced and defined how field epidemiology and public health are practiced on our planet.