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Reprint (Oct 1982)
Letters to the Editor
On the proper role
for an epidemiologist.
In May 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 preceeding 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
the 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, iills,
and dead (includes most CDC’ers) 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
Also, in
presenting findings, should an epidemiologist state, for example, a
kitchen inspection revealed numerous deficiencies in food handling
practices, equipment
maintenance,--any one of which could 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 ice 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 that they
would do well to emulate the precedent 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 analysis 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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Reprint (Nov
1982)
Letters to the Editor
On
the proper role for an epidemiologist---Another view
In at the October 1982 Epi Monitor Dr. Oscar Sussman
wrote a thought-provoking piece on the epidemiologist’s role during
outbreaks. While I was not directly involved with the outbreak Dr.
Sussman described, I was the epidemiologist who investigated the
subsequent two outbreaks. Thus, I have direct knowledge of the
institution and problems involved.
An
epidemiologist is a consultant often invited to investigate a specific
problem. As Dr. Sussman suggests, the epidemiologist should not be
expected to function with blinders on. For example, suppose witnessed
a hospital staff member choking a patient. What should be done? Nobody
would argue with Dr. Sussman that under these circumstances "and
epidemiologists should seek to change conditions then and there."
However, in less dramatic and obvious circumstances, the impetus for
change should be directed to those officials who bear the
responsibility and line authority to rectify problems. "Raising hell;"
"reading the riot act; and” lowering the boom” are
generally poor techniques of communication. Often such
an approach is polarizing.
If an adversary role is created from a consultant being
perceived as overly aggressive, the main points of the consultant’s
thesis are lost in the ensuing battle of personalities. Issues become
obscured as each party seeks to be “right.” Rather, the consultant
should seek to convince through gentle persuasion, logical argument,
and demonstration of strong evidence in support of the hypothesis and
recommendations. The choice of intervention strategy should be geared
to the urgency of the situation. It is well to bear in mind however,
that the carrot often works better than the stick.
Two camps
Dr. Sussman implies that epidemiologists dichotomize
into two camps: the uninvolved attack rate calculators (“most CDC’ers")
and the “hell raisers." I suggest that we are distributed along a
continuous spectrum and the two camps he describes lie outside two
standard deviations from the mean. Clustering about the mean are those
epidemiologists whose findings are supported by data, and whose
communications are tactful, objective, and still forceful.
Dr.
Sussman suggests that epidemiologists are protected from not “being
invited in” to investigate because where else would managers take
their epidemic epidemic business? The answer I fear, is nowhere. Most
epidemiologists are aware of past outbreaks that were allowed to rage
on because of ignorance, indifference,
coverups and publicity concerns. Let us not add fear of adversity to
the litany of reasons that managers choose not to investigate
problems.
While the adversary “hell-raising” approach may
occasionally work in the short term (it did not work in Dr. Sussman’s
case), it may lessen the likelihood that future problems(and
opportunities to learn from them) will be investigated. I am not
suggesting that an epidemiologist should refrain from forcefully
stating the cases. I suggest that this be done dispassionately, and
in a manner that allows management to be a partner and not an
adversary. Farr’s “arguing fearlessly for recommended changes
regardless of what vested interest may be involved" does not mean that
the epidemiologist must shout to be heard.
Jeffrey Jay Sacks, MD, MPH
Published November 1982
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