By Perri Smith

In the mid-1990s, an outbreak plagued the Bay Area Hispanic community.  Numerous individuals developed fevers, chills, nausea, and diarrhea, all symptoms of Salmonella. At the time, no one knew what was happening—what was the source of the illness?  Why was the outbreak only affecting the Spanish-speaking community? And most importantly, whom do you call to figure it out?

The Ghostbusters of the infectious disease world, the CDC’s Epidemic Intelligence Service (EIS) worked diligently to identify the source of the outbreak and stop the disease. They conducted interviews, collected patient histories, and determined possible connections between cases. This is the crucial work of the EIS: the hunt for origins of outbreaks.

The EIS program began in 1951 in response to threats of biological warfare during the Korean War. Run by the Centers for Disease Control and Prevention (CDC), the program is part of the Commissioned Corps of the United States Public Health Service.

“It’s an arm of the military; there are uniforms and ranks,” explains Dr. Bonnie Maldonado, who currently is a professor of Pediatric Infectious Diseases at the Stanford School of Medicine.  Since its establishment, EIS officers have worked on the front lines of most major health issues including pandemic flu outbreaks, mental health issues following natural disasters, and occupational health hazards.

Like pursuing a career in the military, the EIS can be both exciting and challenging. The EIS provides training and real-life experiences for health professionals interested in practicing epidemiology in the field, which can include potentially dangerous unknowns. The highly selective program accepts individuals who have completed graduate level degrees in health-related fields.  Once accepted, the participants are placed in a variety of specialties, from “Chronic Disease Prevention and Occupational Safety and Health” to “Environmental Health and Emerging Zoonotic Infectious Diseases.” The program is two years long, and officers are stationed in one geographic location for the duration.

In the mid-1990s, Dr. Sara Cody was the EIS officer assigned to the Bay Area. Cody used her Spanish fluency to connect with the Hispanic community. She learned about Hispanic culture to pinpoint the source of the Salmonella outbreak, which, in this case, was cheese made with raw milk for Hispanic markets. Today, Cody is Deputy Health Officer and the Communicable Disease Control Officer for the Santa Clara County Public Health Department. Her EIS experience proved valuable to her eventual career.

In addition to offering field experience, the EIS provides an intimate community and mentorship opportunities. Both Cody and Maldonado credit their time with the EIS as an extraordinary opportunity to gain access to the field of epidemiology.  Although Cody relates her time as a trainee to that of a “worker bee,” she also boasts about the advantages of this tireless work.

“In exchange for being a worker bee, you build a lot of contacts, and you’re networking,” Cody explains. “You get to see from the inside how things really work… You [gain knowledge] that you never learned in the classroom, that you just learned from life experience.  You have to figure out what you want and how you integrate it and put it together to crack a problem.”

By investing in EIS officers, the CDC essentially invests in its future.  A majority of current CDC physicians were trained through the EIS program, and Maldonado estimates that one third of EIS officers go on to work at the CDC, while the other two thirds go into practice or academia.

However, the EIS model has its disadvantages as well. As a government agency, the organization and management of the EIS can lead to different outcomes than in another organization.

“There’s always an agenda when money comes,” notes Maldonado. “It’s true for a private foundation or industry. The thing that’s a little bit different about the way the government, at least the CDC, agenda is formed is there’s this overarching theme of health, and if possible prevention.

“And within that, it’s such a broad area so that different mandates can come through.  Some of them make it to the CDC; some of them don’t make it; or some of them make it in a different form than they were originally meant to be.”

Indeed, regulations can evolve greatly from the time they leave Washington to the time they arrive at CDC headquarters and field sites.  For example, policymakers may allocate money towards obesity without specific guidelines for expenditure. Since the obesity epidemic is so broadly defined, the CDC can determine how much money is allotted to upstream and downstream affects, effectively altering policy through interpretation. Nonetheless, mandates from Washington, however specific or broad, are the ultimate guidelines within which the CDC, and in turn, the EIS, must operate.

To further complicate matters, the EIS program and other government organizations must deal with congressional oversight and the rapid turnover of elected officials.  In the past, political agendas have conflicted with investigations.   Maldonado relates the story of an EIS officer conducting abortion surveillance in the 1970s or 80s, a time during which abortion was particularly controversial.  The funding for his surveillance slowly dwindled until he ultimately left the program. The officer eventually established his own organization studying reproductive health. As in this situation, the political orientation of an administration can affect the allocation of money to controversial programs.

This example underscores the effect that policymaking can have downstream on healthcare practices.  Despite the EIS officers’ hard work on the frontline of disease outbreaks, they do not have final say in preventing and addressing disease.  Their work informs policy, but the ultimate decision lies with policymakers, which can have broad economic and political implications.  In the case of the Salmonella outbreak in California, officials shut down the cottage industry of queso fresco, benefitting the established dairy industry. In a similar outbreak in Washington state, officials preserved this cultural tradition by teaching safe cheese processing.  The EIS operates in a circular relationship with policymakers: their work is dictated by prevailing policy and informs its future creation.

 

Bios:

Dr. Sara Cody earned her MD from the Yale University School of Medicine.  She currently serves as the Community Disease Control Officer and Deputy Health Officer in the Santa Clara Department of Public Health.

Dr. Bonnie Maldonado received her MD from the Stanford University School of Medicine.  She currently works as a professor in the Pediatrics department specializing in infectious disease at the Stanford University School of Medic