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Epi Wit & Wisdom Letters
On the Proper
Role for an Epidemiologist
In May of 1982, a large
mental hospital in Florida was involved in an epidemic of vomiting and
diarrhea. The same hospital was involved in a similar epidemic
affecting the same ward areas in 1979. At that time, a top-notch
CDC-type epidemiologist investigated the situation. He did not find
the causative agent, but he did prepare a good protocol to prevent and
limit spread. The protocol was formally adopted, but never effectively
implemented.
Recent Outbreak
Investigation of the most
recent outbreak revealed that for the preceding six months and
continuing through day eight of the outbreak, the institution had an
overflowing drain with sewage leaking onto the kitchen floor. Food
preparers lifted contaminated boxes from the floor to food preparation
counters. Soap, towels, and thorough application of them in proper
order after going to the toilet was lacking on the part of the
employees. Toilets with open doors led directly to the kitchen in the
midst of a massive presence of flies. The serving of tea was by means
of a glass dipped by hand in a large tub. The person serving had one
thumb with grossly visible dirt under the nail.
Results
In a meeting with
management, the epidemiologist investigating the outbreak “raised
hell;” “read the riot act;” or “lowered the boom” as variously
described by those present. The epidemiologist did this to stress the
importance of basic hygienic practices. The net result was that the
management requested removal of the epidemiologist rather than
hurrying to correct the grossly apparent unhygienic practices. State
officials agreed to management’s demands since in their words “the
epidemiologist’s effectiveness in this situation had been compromised
beyond repair... and he had upset some people at the hospital.”
Questions
The above episode raises a
number of questions about the proper role and responsibility of an
epidemiologist. I suggest a dialogue might be useful between
epidemiologists who believe their primary task is only to record the
facts and count the wells, ills, and dead (includes most CDCer's), and
some epidemiologists, including myself, who believe that a more active
role is appropriate. The former group believes an epidemiologist’s
task is to determine the cause of the outbreak; make recommendations
for prevention; and bow out leaving enforcement solely in the hands of
an administrator, inept or not. In contrast, I believe that if a
series of obviously bad breaks in basic hygienic practices are noted,
an epidemiologist should seek to change conditions then and there,
without waiting to prove that these conditions have something to do
with the specific problem under investigation.
More Questions
Also, in presenting
findings, should an epidemiologist state, for example, a kitchen
inspection revealed numerous deficiencies in food handling practices,
equipment maintenance, and hygiene - any one of which could
potentially have led to a foodborne outbreak, or should a more
explicit approach describing all the observations be used (e.g.,
kitchen floor was flooded with water and sewage; ward and food
preparers did not have soap and towels; a food server dipped hand in
iced tea, etc.) Would this latter explicit method be more informative,
although more embarrassing to management?
Getting Invited
It appears that CDC and many
State employed epidemiologists depend on being “invited in” to assist
in epidemic situations. They state, therefore, that they cannot bear
down too heavily on management by using open, explicit forms of
expression. Managers might take their epidemic business elsewhere but
where? What do your readers think?
Oscar Sussman, DVM, MPH,
JD
[Editor’s Note: Two
additional outbreaks have occurred at the above institution in August
and September 1982. Clostridium perfringens was implicated in the
latter outbreak.
In discussing the
proper role of modern epidemiologists, Alexander Langmuir
has suggested they would do well to emulate the precedents set by
William Farr (IJE 1976; 5; 13 - 18). For example “...he did not cleave
to the neutrality that his office could have afforded. He presented
his analyses with objectivity but then stated his own interpretations
forcefully and argued fearlessly for his recommended changes
regardless of what vested interests might be involved.”]
Published October
1982
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