Mark Pendergrast wraps up the Inside the Outbreaks Book Club

Mark Pendergrast writes: It's time to wrap up this ScienceBlog Book Club on my book, Inside the Outbreaks. I want to thank Liz Borkowski, Steve Schoenbaum, and Karen Starko for their excellent, insightful commentaries, and thanks too to those who commented here. I assume that you can continue to do so, and you can also contact me through my website at www.markpendergrast.com. While you're there, on the Outbreaks page, take a look at the YouTube link to the children of Niger singing. It's quite wonderful, and it also has an important message at the end.

I don't regard this as the end of the blog but as the beginning of your reading and thinking about public health and the impact of the Epidemic Intelligence Service. So, as food for thought, here are three sections of the book involving EIS officer Richard Levine, who was a bit of a troublemaker. These sections all involve important issues: environmental toxins, politics and business, mass psychosomatic illness, and iatrogenic illness (cholera spread by the cholera treatment center itself):

The Dusty, Leaden Streets of El Paso

When an El Paso, Texas, health officer called to ask for help evaluating a possible lead contamination problem, Phil Landrigan and fellow EIS officer Stephen Gehlbach met in Texas on March 27, 1972.

The 828-foot tower of the American Smelting and Refining Company (ASARCO) had dominated the El Paso skyline since 1887. ASARCO transformed ore into lead, copper, and zinc, and in the process spewed 313 tons of tiny lead particles into the air in 1971 alone. A local study had revealed heavy metal pollution of the soil.

When Landrigan and Gehlbach analyzed blood from children in El Paso's nursery schools, they found that twelve of the 485 children had levels above 40 micrograms per 100 milliliters, at that time considered the health danger threshold.∗ Eleven of those children lived within three miles of ASARCO. Four Mexican-American toddlers who lived in Smeltertown in the shadow of the ASARCO tower had levels above 80 micrograms, though none had symptoms of acute lead poisoning.

Over the next few months, Landrigan directed randomized studies around the ASARCO plant. Household dust in Smeltertown was found to contain up to 22,000 lead particles per million. Air sampling revealed lead particles in the air near the plant, but they rapidly decreased to background levels three miles away. Most of the particles were smaller than 5 microns, so they could penetrate and remain in the lungs. The children of Smeltertown were swallowing and breathing excessive amounts of lead.

In June 1973, Landrigan returned to El Paso where he and Randy Whitworth, a University of Texas psychologist, studied a group of Smeltertown children with blood-lead concentrations over 40 micrograms per 100 milliliters, comparing them to other local children with lower lead levels. They gave them IQ tests (in Spanish when appropriate) and measured their wrist reflexes. The children with higher blood-lead levels had lower IQ and slower reflexes. Lead poisoning represented a continuum of health problems.∗

Landrigan stayed at the CDC following his EIS experience and eventually headed a new environmental health section. As a result of his work, the new U. S. Environmental Protection Agency eventually tightened industry standards.

EIS officer Richard Levine, stationed in Alabama, had helped Landrigan with the initial El Paso smelter investigation. Fired up about the lead issue, Levine called Alabama's air pollution section in the summer of 1972. Employees there showed him letters from a farmer adjacent to a secondary lead smelter in Troy, Alabama, that reprocessed car batteries. The farmer wrote that his cows were sick. Some had died.

In September 1972, Levine discovered that nine employees of the Troy plant had been hospitalized over the previous two years with symptoms of lead poisoning. Roscoe Moore, a veterinary EIS officer, came to help with the investigation. Levine, an aggressive New Yorker, and Moore, an African-American, annoyed conservative white Alabama officials. Their findings irritated them even more. "The families living adjacent to the smelter reported that since 1971 at least 21 dogs and cats had died after several days of vomiting, ataxia, irritability, apparent blindness, and convulsions," Levine and Moore reported. Thirty out of 37 plant employees had blood lead levels over 80 micrograms per 100 milliliters.

Levine wrote a damning report and distributed copies to his boss and other state health authorities. "When I came in the next day, my desk had been ransacked," Levine recalls. "All my notes and copies had been destroyed." Alabama State Health Officer Ira Myers, an EIS alum, tried to have Levine recalled to Atlanta. Levine was sued by the lead company for libel and slander but was cleared in court.

Levine and Moore were finally able to publish their lead smelter investigation in 1976. "A disturbing postscript to the present episode," they wrote, "was the discovery that between July 1973 and January 1975, 21 additional workers from the Troy smelter were diagnosed as having had lead poisoning and six were hospitalized."

∗ The safe level is now considered 10 micrograms or lower.

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Visual Chain of Transmission

Friday afternoon, May 11, 1973, the Fayette County, Alabama health officer reported an outbreak of violent itching and rash at an elementary school. About a quarter of the 366 students had become ill, and 48 students and three teachers had been taken to the hospital. Aside from the rashes, victims suffered a variety of ailments, including headaches, cough, nausea, vomiting, weakness, sore throat, burning eyes, abdominal pain, numbness, shortness of breath, and diarrhea. Twenty-one students lost consciousness for a time. Most recovered quickly, but a few remained hospitalized overnight.

The following morning, Alabama-based EIS officer Richard Levine drove to Fayette County Hospital in the town of Berry. Levine examined the patients, including a teacher who told him, "It was like there was Red Devil Lye splashed all over my skin." The victims had no fever, no abnormal white cell count. The fading rashes were mostly on the patients' extremities, in areas where they had scratched. Levine told the school principal that he saw no reason to cancel school on Monday.

The EIS officer went home, and then returned on Tuesday to find the school nearly empty. There had been another outbreak. Eighteen students were afflicted. Most had also been in the first epidemic.

Levine called the CDC for help. EIS officer Fred Romm came from Atlanta with a sanitary engineer. EIS officer Dan Sexton came from Mississippi with John Kaiser, a fourth-year medical student taking an epidemiological elective. The CDC engineer set off smoke bombs to study air circulation. The investigators examined seating charts to see who sat next to an open window. No meaningful patterns emerged.

The outbreak appeared to be limited to the elementary school. Because of the rapid onset and lack of fever, it probably wasn't an infectious disease. Investigators collected information on chemicals used at the school but found no answers.

Levine and Sexton gradually pieced together the story. Shortly before the morning recess on May 11, two sixth grade girls, both vigorously scratching themselves, were sent out of class to sit on a bench at the end of the main hallway. During recess, their concerned friends from the 5th and 6th grades gathered around them. They, too, began to itch and scratch. Some ran into the restroom to splash water on their burning skin. Students already in the bathroom became affected. "A few minutes later the 4th grade recessed and joined the commotion at the end of the hallway," Levine wrote in his Epi-aid report. Soon fourth graders also began to scratch themselves.

Third graders waiting for lunch caught the itching plague as well. The first and second graders, already at lunch, were mostly kept free of the ailment, while the special education students in a distant classroom remained totally unaffected. Shortly after noon, the desperate principal evacuated the school. The skin of several teachers began to burn as well.

On Friday, May 18, Levine was interviewing seven 5th and 6th grade girls who had suffered repeated attacks. "I've got an itch!" a fifth grader announced. She began scratching herself violently. The other girls followed suit, scratching so hard that they began to bleed. Two fifth grade boys came into the room. One began to scratch. The other developed a sympathetic rash without touching himself.

Having witnessed this third epidemic himself, Levine was convinced that it was mass hysteria. Those who came down with the ailment simply had seen someone else suffering from it -- a "visual chain of transmission," as Levine eventually wrote in a published article. As with most such episodes, the majority of the victims were female.∗ The only ones exempt were the special education students - perhaps because they were not "smart" enough to become ill. After the third outbreak, the local board closed the elementary school for the rest of the year, which was nearly over anyway.

∗ Industry and regulatory officials often assume no toxic effect below certain levels, leading to a "hockey stick'" graph with a straight line showing no effects until the critical level is reached, then the "stick" part of the graph with a straight line rising above that level.

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The Cholera Center

After a little over a year in Alabama, having witnessed a hysterical epidemic and enraged state officials with his reports on lead, Richard Levine took a position at the Cholera Research Lab in Bangladesh conducting vaccine trials for the balance of his EIS service.

Day or night, speedboats brought patients from 234 nearby villages. From the upper deck of the old prison barge where he lived three days a week, Levine "saw the boats come in with cholera patients and their family members. People would be pooping in the boat on the way down." Employees flipped the boats over and washed the diarrhea, replete with cholera vibrio, into the adjacent canal. Family members, often asymptomatic cholera carriers, excreted directly into the canal. In addition, the hospital sewage system leaked into the waterway.

Examining hospital records, Levine found that during five epidemics occurring from November 1968 through February 1971, the cholera hospitalization rate in "area C" on the canal was 15.6 cases per 1000 people a year, compared to a rate of 2 cases per 1000 in all villages. The re-infection rate for area C was 13 times as high as other villages. "Contamination of canal water can overcome any immunity resulting from repeated exposure," Levine wrote in one of two papers reporting his results.

Once again, Levine was the bearer of controversial news. Even though he carefully concluded, "The benefit of the hospital to the community in terms of lives saved greatly outweighs the few extra cases in the hospital vicinity," CDC authorities would not approve the papers. So Levine and his co-authors submitted them to the British journal, The Lancet, which published them. Soon thereafter, new sanitary precautions were initiated.

∗ Why females appear to be more susceptible to psychosomatic disorders is a contentious issue. Explanations include: 1) Women are more emotional and sensitive. 2) The imagined ailments stem from women's oppression. 3) It is a cultural phenomenon. 4) It is genetic.