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Public Health Heroes 

Book review: Inside the Outbreaks


The Epidemic Intelligence Service is surely the most effective governmental organization you’ve never heard of. Employing only about 3000 people between its creation in 1951 and today, the Centers for Disease Control and Prevention service-and-training program has performed an impressive number of feats on behalf of public health.

Know why there’s no mercury in your latex house paint? An EIS officer advised the Environmental Protection Agency to ban it in 1989 after a Michigan toddler died. Remember when it became clear that AIDS could be contracted via blood transfusion? A cadre of EIS officers made that discovery. The EIS is the reason we do not give aspirin to sick children. It’s why women seeking to get pregnant know to increase their folic acid intake. And the list goes on.

In Inside the Outbreaks, Colchester author Mark Pendergrast documents a large number of these epidemiological breakthroughs from the last 59 years. Surprisingly, he’s the first to do so. (Two previous accounts of the EIS focus on specific periods during the organization’s lifetime.) In this work based on interviews with 500 EIS alums and seven years of research, Pendergrast expertly summarizes hundreds of cases — mostly the successful ones, he admits in an intro — in roughly chronological fashion. Letting the cases speak for themselves, he creates an extended argument for the value of spending public money on public health. The book, Pendergrast’s fifth nonfiction work, couldn’t be more timely.

Or inspiring. The book’s cartoon-panel cover, featuring Cary Grant look-alikes, one flourishing a test tube and the other sprinting toward fallen patients, turns out to be more than a marketing ploy. EIS officers are responsible for some heroic public-health milestones. Teaming up with the World Health Organization and other key parties, they helped to eliminate smallpox from the face of the planet. They devised oral rehydration therapy, a simple but revolutionary replenishing liquid that keeps cholera patients alive. They helped stem the second flu pandemic, in 1957. (The first, in 1918, killed 20 million people.)

Many of these seminal undertakings occurred under the leadership of EIS founder and epidemiologist Alexander Langmuir, whose directorship until 1970 provides the first of Pendergrast’s three historical sections. The only individual in the book given character description beyond a tagline or two, Langmuir was a domineering sort who sought results. He received permission to form the EIS because the U.S. military had just had its first biological-warfare scare: Hundreds of soldiers in Korea were mysteriously dying of burst blood vessels. (Korean hemorrhagic fever, it turns out, was caused by a virus spread, Pendergrast writes in a succinct footnote, “by rodents, not Communists.”)

Langmuir found ready recruits for his quick-response team among young male doctors trying to avoid the draft. He called his recruits his “boys,” finding little reason to hire women. At the same time, he was staunchly in favor of abortion rights, and sent one pro-life officer on a tour of the poorest sections of the world before assigning him, newly enlightened, to serve the organization’s customary two-year stint. Over the years, nurses and veterinarians were brought on board, and EIS officers today have backgrounds in everything from sociology to law. More than half are women.

EIS officers operate like on-call detectives, responding to disease outbreaks singly or in small groups on a day’s or week’s notice. Trying to determine the source of an outbreak, they work around the clock crawling through air-conditioning ducts, studying recent weather patterns, or surveying affected groups about their pets or water sources. In one 1967 case in which hospitalized infants were dying, agents dismantled and tested everything in the facility from the attic to the basement, where they found launderers using a toxic whitening agent. More recently, Pendergrast himself accompanied three EIS officers on missions to Niger and Kenya, where they tracked insecticide-treated bed-net use and a DIY water-purification program.

Pendergrast notes that, while the EIS has no regulatory power, its director can threaten a media stink. One EIS officer enlisted Ralph Nader to write an exposé of lung disease in cotton-mill workers in the late 1960s, a measure that forced the industry to change its dust-control standards. The EIS has also endured its own occasional savaging by the media, documented intermittently in the last two of Pendergrast’s three sections (1970 to 1982 and ’82 to present), which has led to political fallout and slashed funds. Mostly, though, the organization has flown under the radar.

Readers alert to contemporary public health concerns will find some interesting history in these pages. Who knew that objection to mass vaccination dates back at least to 1964, when Colorado physician Henry Kempe spoke out against routine smallpox immunizations because he believed that “potential adverse effects were not worth the risk”? (The EIS officer on the case was “distressed” at Kempe’s “flawed, inflated figures,” Pendergrast writes.) Similarly, the push for chlorinated water dates from 1965, when a strain of Salmonella in the well-water supply of Riverside, Calif., caused a diarrhea epidemic in 20 percent of its residents, killing three.

Some of the EIS’ more long-term efforts would have been better served by dedicated narratives than by Pendergrast’s one- or two-page case summaries. The EIS has been tackling polio and malaria for decades. To follow the thread of the organization’s efforts in either arena, one has to turn to the index for a list of related cases scattered throughout the book.

In fact, a unifying narrative is the one thing missing from Inside the Outbreaks. Pendergrast’s strict adherence to an episodic, case-by-case format means that overarching concerns — such as how the EIS fared under successive leaders or presidential administrations, how it has interacted with pharmaceutical companies, and how often its recommendations have been implemented — are addressed sporadically. As for an inside view of this elite public health corps, Pendergrast mentions only its tradition of self-mockery in annual skits and cartoon-adorned diplomas. Without a character-driven narrative, the reader is left wondering what the culture of this largely unknown organization is like and how it has evolved.

But, the EIS’ modus operandi of vaulting anywhere on the planet on short notice for a different cause each time does not lend itself easily to a single narrative (though it would make a great “CSI”-type television show). Pendergrast is more interested in the heroic exploits of individual officers.

His book thus performs a double service. The compilation of case histories shows indisputably that it’s far more cost effective to pay the government to stem public health problems at the source than to rely on the private sector to treat the dozens — or millions — of people who would otherwise fall sick. Investing in public health, in other words, pays.

And, by documenting in spare language and without fanfare the real-life heroism of hundreds of public health detectives, Inside the Outbreaks may well leave even the most adamant Tea Party member swelling with pride in our government.

Want to see for yourself?

Inside the Outbreaks: The Elite Medical Detectives of the Epidemic Intelligence Service by Mark Pendergrast, Houghton Mifflin Harcourt, 418 pages. $28.

Mark Pendergrast appears on Vermont Public Radio’s “Vermont Edition” on Thursday, April 29, at noon. He will sign books at Barnes & Noble in South Burlington on Thursday, May 6, at 7 p.m. and at the Dartmouth Bookstore in Hanover, N.H., on Tuesday, May 11, at 6 p.m.

From Inside the Outbreaks:

EIS officer Mike St. Louis was dubbed the “eternal freshman” for his unquenchable enthusiasm. His primary work was to explore why Salmonella enteritidis epidemics kept occurring, particularly in the northeastern United States. In June 1986 St. Louis investigated a multistate S. enteritidis outbreak associated with frozen lasagna, jumbo stuffed pasta shells, manicotti and ravioli made by Rotanelli Foods at a production plant in New Rochelle, New York. St. Louis traced the problem to raw eggs in the cheese stuffing. The products were labeled “Fully cooked. Just heat and serve,” but many people did not heat the food sufficiently to kill bacteria. The company subsequently changed the label and switched to pasteurized liquid eggs.

By the spring of 1987 the CDC had been alerted to sixty-five S. enteritidis outbreaks in the northeast in the prior two years, most traceable to raw or inadequately cooked grade A eggs. St. Louis looked back at the 1973-1984 register of Salmonella outbreaks, searching for egg ingredients. He compiled impressive statistics linking S. enteritidis with eggs.

EIS officers had made the egg-Salmonella link twenty-five years before, but past outbreaks had been traced to fecal contamination of cracked or soiled eggs. The modern Rotanelli plant had purchased unblemished large white eggs and then disinfected their exteriors. St. Louis buried himself in poultry research and found a 1944 article in the British Medical Journal stating that S. enteritidis could persist in the ovaries of chickens. Could the hens actually be depositing bacteria inside the intact eggs they laid? He published the suggestion in the Journal of the American Medical Association, raising a storm of protest from the egg industry.

Illinois-based EIS officer Sue Trock incubated whole eggs from an implicated farm, washed and flame-sterilized them, then cracked and cultured them. She found an abundance of S. enteritidis. Until then, eggs had been considered perfectly packaged natural products requiring no refrigeration. Illinois was the first state to demand chilled eggs (to prevent bacterial proliferation), even in transport, and the FDA soon followed suit.

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About The Author

Amy Lilly

Amy Lilly has been a contributing arts writer for Seven Days since 2007.


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