Book Review
Battling Bugs
Two recent books tell the stories of the Epidemic Intelligence Service and MRSA with varying success.
A large part of a physician’s job is knowing when something is wrong and what to do about it. The signs or symptoms can be as subtle as a minor limp or a tickle in the throat. Divining when the seemingly benign becomes the darkly suspicious requiring an MRI or a chest X-ray is a product of training, experience, attitude, and luck. That daily dance between patient and doctor is replayed on a wider scale by epidemiologists, the doctors of society who listen with their “stethoscopes” (surveys and data) to the heartbeat of their community. Like practicing physicians, epidemiologists collect war stories of obscure clinical puzzles solved, disasters averted, and, sometimes, diagnoses missed. Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service and Superbug: The Fatal Menace of MRSA are battle narratives from the saga of keeping the public healthy.
Inside the Outbreaks is a history of the Epidemic Intelligence Service (EIS). Founded in 1951 as a service/training program working out of the Centers for Disease Control and Prevention, the EIS employs a wide array of science professionals such as doctors, dentists, and statisticians to be “shoeleather epidemiologists,” answering calls from around the world to define new diseases or investigate old ones flourishing anew. Responding to fears of biological warfare that surfaced during the Korean War, the EIS’s autocratic godfather, Harvard-trained Alexander Langmuir, M.D., envisioned a quasi-military strike force that would mobilize quickly to attack a problem using as its primary epidemiological weapon the cohort study, which defines a group of people, compares their behavior, and looks for differences between those who became ill and those who did not. Langmuir tried to boil the process down to numbers, describing normal behavior with statistics gathered from routine surveillance and looking for suspicious blips that might signal trouble.
Journalist Mark Pendergast’s history is really a chronology, and that is both its strength and its weakness. He methodically plods through the 50-plus years of the EIS describing case after case with one- to three-page summaries. His portrayals are succinct and give the flavor of each epidemic or outbreak including the 1976 outbreak of Legionnaires disease in Philadelphia and the 1993 infestation of Milwaukee drinking water with cryptosporidiosis. But his glorified timeline chops each story into disjointed bits; the story of the eradication of smallpox, for example, pops up in multiple fragments over some 100 pages. Each chapter has subsections that are either totally unrelated or tied together with some weak segue. It’s almost as if Pendergast was trying to borrow the novelist’s technique of using multiple concurrent stories told in snippets that eventually merge into a big picture. Inside the Outbreaks’ snippets never converge.
The scattershot, multiple disease approach of Pendergast’s book contrasts with the focus of science journalist Maryn McKenna’s story of the blossoming of resistant Staphylococcus aureus in the United States. The overly melodramatic “fatal menace” description in the title and the cover blurb—“Medicine disregarded it. Antibiotics can’t control it. MRSA-drug-resistant staph may be the most frightening epidemic since AIDS”—belie what is fundamentally an excellent summary of the journey of S. aureus from just another bacterium universally covered by penicillin to a wily pathogen that changes its DNA almost as fast as new antibiotics are developed.
Released in 1959 as a highly-touted magic bullet for S. aureus, which was rapidly becoming resistant to the era’s panacea—penicillin, methicillin gradually suffered the same fate as its precursor. But as the bacterium became resistant to methicillin, the scattered cases of MRSA in large hospitals in the 1960s became regular events in all hospitals in the 2000s. Today, 90 percent of S. aureus isolates found in some hospitals are MRSA.
In recent years, MRSA has also migrated from an infection afflicting the ill, hospitalized, and immune-compromised to a sometimes fatal infection that can strike a previously healthy individual. As McKenna says, “The terms that had described MRSA for decades were no longer useful, because the bacterium itself was no longer behaving as it had for all those years.”
Although most MRSA infections in otherwise healthy individuals have manifested as treatable skin infections, fatal infections occupy a disproportionate share of McKenna’s book, with dramatic stories of adults and children who go from normal existence to death in a matter of hours. These horrific sketches usually introduce different facets of MRSA, some of which are well-covered in the medical literature such as epidemics in prisons and occurrences that originated in athletic facilities and locker rooms. Others are less well-documented such as the infection of pigs and elephants and the possible reciprocal transmission from man to animal.
Does McKenna prove her cover-page claim that medicine disregarded MRSA? That depends on how you answer the question, When do scattered cases become an impending epidemic requiring enhanced surveillance and stringent control measures? Like knowing whether a recurrent headache may indicate a brain tumor, the key is knowing when to accelerate suspicion from low to high. And that’s why we need well-trained epidemiologists and doctors—and more than a bit of luck. MM
Charles Meyer is a practicing internist and editor in chief of Minnesota Medicine.