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16 Dec 2002

Source: Atlanta Journal-Constitution , August 30, 2002.

New troops enlist at CDC to fight disease

By M.A.J. McKENNA , Atlanta Journal-Constitution Staff Writer

ANNISTON, Ala. -- In a concrete block hallway, nervous health workers crowd around a body on a gurney. They are shrouded in baggy white coveralls, thick boots and black rubber gloves that reach their elbows. Heavy respirators mask their faces.

The body on the gurney is a training dummy. But to the drill instructor barking orders at the class, it is a victim of a poison gas release.

"I know your training is to get the patient to treatment ASAP," the instructor says. "But you need to cut his clothes off first. You need to wipe him down with decontaminant. If you rush into the ER with this person, other people are going to die. You have to remember: You're in a new era now."

For 51 years, the disease detectives of the Centers for Disease Control and Prevention have been first on the scene of AIDS, Ebola and West Nile virus. Now the newest group of them -- M.D.s and Ph.D.s who started work last month -- must learn what it will be like to handle a terrorist attack.

The Epidemic Intelligence Service -- the formal name of the CDC's disease detective corps -- is the best known, and to outsiders the most glamorous, part of the agency. It is the rapid response force, featured in movies and best sellers, that always keeps a bag packed and can parachute into disease outbreaks overnight.

Like the rest of the CDC, the intelligence service is at a pivotal moment. Concerns about terrorism have transformed the Atlanta-based public health agency. Hundreds of staff members have been reassigned, budgets boosted and new labs and programs launched with unusual speed. And the service, a group founded at the height of the Korean War to investigate whether troops had been infected with biological weapons, is facing the reality of responding to bioterrorism for the first time.

New officers, as they are called, arrive every July. They serve two years of long hours at relatively low salaries, some in Atlanta and others in state health departments. In return, they get one of the most valuable credentials in public health and the chance to participate in the history of a group that helped eradicate smallpox, identify AIDS and solve the first major outbreaks of Legionnaires' disease, toxic shock syndrome and E. coli 0157.

"This is a critical time for the program," said Dr. Douglas Hamilton, a tall, genial microbiologist and family physician who has headed the corps for five years. "The focus of the country is turning to recognizing the potential for terrorism. But our mission is training epidemiologists, and epidemiology is not only finding a terrorist who is spewing anthrax. It's dealing with a whole range of health problems."

This year's class is the largest in corps history, due to extra funding voted by Congress. There are 89 members, ranging from 26 to 49 years old: 32 men and 57 women; 75 Americans and 14 internationals; 63 Caucasians, 14 Asians, nine of African heritage and three whose background is Spanish-speaking.

There are 56 physicians, 23 Ph.D.s, seven veterinarians, two nurses, a lawyer and a dentist; seven Phi Beta Kappa members, six college athletes and four Peace Corps volunteers. Two of them are married to each other. One is pregnant. Nine of them have children who are not walking yet.

They gathered in early July in a windowless modern conference room on the CDC's headquarters campus, sitting in alphabetical order, starting a month of days that would begin at 8 a.m. and sometimes go late into the night.

"We want them to be bonded as a group," said Hamilton, who joined the Epidemic Intelligence Service after hearing about it at his 20th high school reunion and served in Connecticut, Kazakhstan and Kyrgyzstan during his two years. "If we face a situation again like the anthrax attacks, the cohesion they have developed will help to pull them through."

Akin to boot camp

The service's first weeks of training are the classroom equivalent of boot camp: hours of lectures on the basics of finding cases, handling lab samples and respecting the rights of patients. The jargon piles up rapidly: case control study, prevented fraction, population attributable risk percent.

"I advise you to fasten your seat belts," instructor Polly Marchbanks tells them in the first week. "This is going to be difficult."

Morning classes deal with theory: how to design a scientific study, write a questionnaire and run sophisticated software that can reveal disease trends. Afternoons are reserved for case studies of epidemics.

On a steamy afternoon, 10 new officers cluster with Hamilton in a cinder block basement classroom as he leads them through a 1999 investigation: seven children in Albany, N.Y., who have bloody diarrhea after visiting a county fair.

"Is this an outbreak?" he asks.

"An outbreak is more cases than expected in a certain time and place," replies Waimar Tun, an epidemiologist with experience in Bangladesh and Tibet. "We don't know what that baseline would be."

"So is it worth investigating?" Hamilton prods.

"The state health department asked us to investigate," Angela McGowan says. "When they ask us, don't we go?"

Hamilton nods. "We do investigations first to control disease," he says. "We do them because they are good training. And we do them to respond to public and political concern -- those are always important."

McGowan makes notes. Her presence is one sign of changes in the Epidemic Intelligence Service: She is the first lawyer accepted into the program. She is also a second-generation officer, born during her father's service 31 years ago.

"I always heard about it, and I was never going to do it," she said. "I was an international relations major as an undergrad, and in law school I went into a foreign relations program. But then I got interested in health after all. I realized that people make laws and people do research -- but no one looks at the policy that links them. That's what I want to do."

The New York diarrhea cases, it turns out, were part of a huge outbreak: more than 760 cases of E. coli, traced to an unchlorinated fairground well. But when investigators arrived, Hamilton reminds them, no one knew the source of the problem. It is an opportunity to reflect on risks they may run.

The work can be dangerous. One member died in an African plane crash in the 1960s. Officers at the 1999 World Trade Organization meeting in Seattle were accidentally tear-gassed. Those who work on Ebola outbreaks have seen African doctors die from a slight lapse in self-protectiveness.

"It is vital that you take care of yourselves," Hamilton lectures them. "If you get sick, you will not do anyone any good."

A field assignment

Epidemic Intelligence Service officers need skills that classroom experience cannot teach: curiosity, resourcefulness and cultural sensitivity.

In their third week of training, they get an opportunity to exercise them. The DeKalb County Board of Health asks the class to conduct a survey of whether restaurants are observing a no-smoking ordinance.

It is their first taste of the core technique of CDC-brand research: conducting face-to-face interviews to draw out data for computer programs to crunch. (The service calls it "shoe leather epidemiology" and proudly uses as its symbol a shoe sole with a hole worn in it.) But it is the officers' first experience also with how their carefully gathered statistics might be used.

"You folks are at a point in your career where you're focusing on data," says Dr. Scott Wetterhall, Class of 1984 and now a DeKalb employee. "But data has to go somewhere, and where it usually ends up is tangled in politics."

So one blazing Saturday morning, new officers Leigh Ramsey and Dr. Jacek Mazurek are standing in the parking lot of a strip mall where I-285 crosses Buford Highway, trying to find a restaurant. They have a name. They are at the address. But the Buddha Express is missing.

"It has to be here somewhere," Ramsey says, frowning at an ad for noodles in a cafe window. "Someone has to know where it is."

It has not been a good morning. At a Waffle House, the manager refused to stop cooking to talk with them. At a Korean restaurant, a waitress who took them for inspectors waved insistently at a "98" health rating awarded two weeks earlier. At a Mexican seafood stand, no one spoke enough English to fill in the blanks on the 10-page questionnaire.

Mazurek is a rehabilitation specialist who trained in Warsaw, Poland, and upstate New York. Ramsey, 31, is an Atlanta native with a Ph.D. from the Medical College of Georgia. Small-framed and cheerful, she wears a bracelet of linked tennis rackets and has run seven marathons. In graduate school, she studied how sickle cell anemia responds when patients exercise.

"I have done lab work -- on blood samples, tissue samples -- and I've worked with people," she said. "But I wanted the experience of studying people in large groups and communities, and working for the EIS offers that."

After 45 minutes of hunting, the two find Buddha Express. It sits behind a pinball arcade and a Korean snack bar, wedged into a bowling alley with black light karaoke bowling and glow-in-the-dark shoes. But the restaurant has changed hands. It is a bar called Scrooge's Lounge now, and it is all-smoking, all the time.

It reminds them of another skill they need: a sense of humor.

New focus: Terrorism

The officers' training used to run three weeks. But last year, every officer who could travel -- 136 of 146 -- was sent to the World Trade Center, the Pentagon and the sites of the anthrax attacks. So this year, the CDC added an extra week of training, devoted only to terrorism and conducted by outside experts.

In the first days of August, the agency bused the group to the Noble Training Center in Anniston, Ala., a former Army hospital whose walls are covered with framed explanations of chemical hazard symbols and posters listing the most dangerous biological agents.

"I hope," Col. Ted Cieslak tells them, "that this week is a waste of all your time."

Cieslak is a pediatrician and a Marine Corps colonel whose brother was an Epidemic Intelligence Service officer in 1992. He worked for years at the Army Medical Research Institute for Infectious Diseases, a Maryland military reservation that led the U.S. biological weapons program.

"Biological agents are the ultimate terrorist weapon," Cieslak said. "In this day and age, with terrorism playing the role it now does in American society, you will all have to go about your business with that possibility in the back of your minds."

The Anniston week is a crash course in nightmares: When to use a Geiger counter. How to diagnose smallpox. When seizures are a sign of a toxic chemical release. How far anthrax spores spread in the wind.

There are lectures on improvising a mask when the air is not breathable (fold a T-shirt and scrunch the fabric over the mouth and nose) and coaching on hand signals to use with a scuba-like air tank: patting the head for "I need assistance," hands around the throat for "I can't breathe." Finally, there was learning how to suit up in coveralls made of impenetrable Tyvek, heavy boots, gloves and respirators -- which came with warnings that beards and bangs would disrupt the air-tight seal -- and how to doff the suits, without contaminating yourself, while standing inside a large plastic bag.

"I cannot emphasize this enough: You are a target, a target, a target," trainer Rick Schlegel told them somberly. "If they take you out, there will be no one to hold the line on the epidemic."

After the suits, the class got an extra-long lunch to recover. In the hospital's old brick entryway, new officer Dr. Wayne Duffus thought about the experience.

"It's good to have to do it for real, to check your tolerance," he said. "The goal is to help people, whatever it takes -- and whatever it takes means taking care of yourself, so you can get to all the people you need to treat."

Duffus, 37, is an internist and a virologist with a Ph.D. A native of Jamaica whose family moved to New York in the 1970s, he began publishing scientific papers in college and spent the past year at Emory on an infectious diseases fellowship. Like Ramsey and about half the class, he will serve his two years away from Atlanta -- in his case, in Columbia.

"I wish I could spend more time with my classmates," he said, looking around. "But I just can't wait to be with the people I'm going to work with. I want to get into the trenches."

West Nile beckons

Almost every year, a new officer is pulled from training early because some part of the CDC needs help. This year, too: Before the month of training ended, one officer was shipped to Texas to investigate an outbreak of disease among prairie dogs sold for pets. Another left two days later for six weeks in Kabul, Afghanistan, helping refugees.

Others got to their new jobs and were sent out within 24 hours. Dr. Susan Montgomery, a veterinarian, drove cross-country to Fort Collins, Colo., the CDC's insect-borne diseases lab -- and was immediately given a ticket to New Orleans to help with the West Nile virus outbreak. Joel Montgomery (no relation), a microbiologist from Texas, got two weeks to settle into a cubicle in the special pathogens branch in Atlanta, the group that works in the high-security labs. On Aug. 11, he left for Bolivia.

Montgomery is used to dangerous organisms and foreign travel: Before coming to the CDC, he had isolated deadly bacteria from Komodo dragons, sticking his hand into the mouths of the poisonous animals while six technicians held the beasts down. But like most of his classmates, he was reeling slightly from the pace. He had scientific papers to finish and new colleagues to meet; while he was in training, his wife, a special education teacher, had moved them into a new house in Lilburn.

"I wanted to move out of the lab, to get away from the organisms and appreciate the human impact of diseases," he said before leaving. "The point of this is complete immersion, to take these two years and do as much as possible. I'm ready to get to work."