THE FEARS OF THE RICH AND THE NEEDS OF THE POOR
Life plans are an illusion. I tell students that they cannot imagine the opportunities that life will present and that they should spend their time developing a life philosophy rather than a life plan.
My life plan was to work in Africa. I had no idea that a two-year stint at the CDC, fulfilling a draft obligation, would capture me for life. I did not know that the EIS program would be one of the best mechanisms yet devised to propel people into global health. I entered this portal through good fortune, not through careful analysis, and only in retrospect realize the role of a mentor in providing this experience—an experience that provides one perspective on the CDC.
I also did not know that epidemiology would be the science base for everything done in public health or that we all use epidemiology daily but unconsciously. We develop our own risk comparisons, both to avoid unpleasant situations or to enhance pleasant ones. Dopamine levels influence how much risk we seek or avoid. We try to avoid contacts with bullies, who might beat us up, and so we observe their habits and know where they are likely to be. We arrange, but make it appear to be by chance, to run into a girl we are hoping to meet. It isn’t chance because we have observed the route she takes walking home from school or when she goes to the library. Epidemiology is a daily companion, even if we’re not aware of it.
Looking back, I now see that I deliberately used the skills of an epidemiologist to get a driver’s license. I passed my sixteenth birthday in a body cast, the result of a hip injury, and expected to get my driver’s license immediately on release from the cast. I was mistaken. My left knee was frozen in extension, and my left ankle had limited mobility. I was told I would never walk again without crutches.
That only fueled my desire for freedom, and soon I was walking without crutches and could focus on getting a driver’s license. The problem with the limited movement in my left leg joints meant that I had to operate the clutch, brake pedal, and accelerator with my right foot. It can be done but with a certain amount of jerkiness in getting started. An automatic transmission would have made it easy, but that is not what we had. The clutch must be released slowly to avoid a stall; the right foot then shifts from the clutch to the accelerator. I could easily go from first to second to third gears without using the clutch, by moving the shifter to neutral and increasing the motor speed so the transmission would mesh. It was only the initial start that was awkward. I could drive safely and would automatically shift into neutral as I put on the brakes, but there was no way I could have passed a road test with an examiner in the car.
Driver’s licenses were awarded once a week in Colville, Washington. A state patrolman would come to our town and give the written and driving tests. I knew the driving manual by heart, but I went to the weekly session on the pretext of getting a book to study. I sat down and pretended to read the book while I watched to see if there were any possible ways to avoid the actual driving part of the test.
Applicants would be given a written test at the counter. They then sat at one of the half-dozen tables to take the test. It was returned to the examiner, and, after grading, the patrolman would take the applicants for the driving test. The license would be issued, and the next applicant would be seen. I noticed, during the middle of the afternoon, when a half-dozen people completed their tests at about the same time, that the patrolman skipped the driving test.
Years later I realized I was practicing epidemiology. The rate (or risk) of a driving test was 100 percent if only one person was in line to have his or her test graded. But the rate (or risk) of a driving test declined when there were others waiting to have their tests graded and declined precipitously when the line was long. So the plan was to get in a long line but be near the head of that line.
The next week I stayed outside the room until a group of people came for their licenses. I entered in their midst, completed the test quickly, and then watched until I saw that four or five were almost finished with the test. I went to the examiner’s desk near the front of the group, with a line forming behind me. Sure enough, within minutes I had a license without taking the driving test. Epidemiology works!
The Lure of the CDC
When J. D. (Don) Millar called me in early 1962 to say that I had been accepted into the EIS program, it changed my career trajectory. I had already been accepted into an internal medicine residency program, but by this time, I was reading the various publications from the WHO and becoming increasingly interested in global health. (Although then it was always referred to as international health or tropical medicine.) There were various ways to get into global health in those days, but few were straightforward. There was little job security and to say there was not much competition is an understatement. Few faculty members at my medical school, other than Rei Ravenholt, had an interest in the subject. At my fiftieth medical school class reunion, a classmate confessed that when I told him I wanted to go into global health, he said to himself, What a waste.
The lack of competition was matched by a paucity of good financial pathways. In those days, every person going into global health cut his or her own path through the morass. It later became clear that one of the few truly good pathways was through joining the EIS. Not only did that program make it possible to become acquainted with people and programs with global interests but also the experiences that made the CDC a gold standard for public health in the United States soon made it a gold standard for global health. Once again, without a clear personal plan, and with little understanding that the EIS was a great career development move for global health, the decision to join the EIS turned out to be career changing.
EIS was developed by Dr. Alex Langmuir in 1951, as mentioned earlier, as a response to concerns that Korean hemorrhagic fever might have been introduced deliberately during the Korean conflict. It had not been, but the fear alone led to one of the most important developments in public health history. This fact reinforced a bias that I developed over the years when resources were so scarce in global health, namely, that the way to improve health equity is to figure out how to link the fears of the rich to the needs of the poor. The rich will respond to AIDS, to Ebola, to drug-resistant tuberculosis, to bioterrorism, because they realize they stand to benefit, as they also are at risk. But it is much more difficult to get them to respond to river blindness, intestinal worms, or even malaria because they don’t feel the threat to themselves. Vaccines in the United States are purchased for all because the powerful realize we are all at risk. For many years, I had told students that Ebola could be one such link, and 2014 proved that point.
To train a group of people to respond to bioterrorism required training them in the common health outbreaks that involve the United States every day. Originally, that meant infectious diseases. Because bioterrorism involved the very security of the country, EIS officers were recruited as military officers, and the two-year program satisfied military draft requirements. One implication of this is that originally all EIS officers were men, as women were not subject to the draft. Another implication was that officers were expected to wear uniforms, thereby making it clear that two personnel systems were involved at the CDC, the Civil Service and the Commissioned Corps. This dress code was accepted at the Pentagon and other places with military and civilian employees, but it often confused people in public health. (It also inspired longtime health educator Hod Ogden to write lyrics for a song, indicating that bureaucrats in Washington, DC, when dealing with the CDC, were “Civil to the servants, but rotten to the Corps.”) Another implication of the draft recruitment was that, while most originally entered to satisfy military service, many found the work so interesting that they became public health workers for life.
A matching process was used in assigning new EIS officers. They were expected to attend the EIS conference, held each April at the CDC, preceding the initiation of their employment in July. They attended the conference meetings but also interviewed with programs with openings for EIS officers. At the end of the week, prospective officers listed the programs they would prefer in priority order. The programs also listed the EIS officers they would like assigned to them in priority order. Most officers and programs got one of their top-three selections.
As a medical student, I had worked for Rei Ravenholt, an early EIS officer, and at the time the epidemiologist for Seattle-King County. He had a high energy level, an infectious interest in a wide variety of subjects, and boldness in taking on anyone, whether the tobacco companies’ causing enormous harm or his fellow physicians’ causing hospital infections. He was always embroiled in controversy but appeared to relish the battle. He was generous with his time to talk about public health issues requiring attention, exuded charisma, and attracted a group of students to help him in his many research projects. He was an enthusiastic promoter of the EIS, and I am grateful that his descriptions caught my interest.
The Value of Available Resources
As a medical student, two projects especially interested me. One was a review of death certificates in Seattle, to understand changing patterns of death classifications and disease in the history of the city. For example, it was possible to get some idea of the role of fatalities due to Staphylococcus organisms by knowing the various names given to staph infections over the years. Or it was possible to plot the change in causes of death due to violence; for example, deaths due to elevator accidents went down as elevators became safer, while automobile deaths went up.
But it was also possible to plot the increased role of tobacco as a cause of early death. The increase in lung cancer deaths led to my first paper in a peer-reviewed journal, as we looked at the life expectancy of patients following a diagnosis of lung cancer (1). The discouraging summary was that there had been little progress in treating lung cancer in thirty years, and the increases in life span after diagnosis were generally the result of earlier diagnosis rather than clinical success in treatment. Few patients survived five years after diagnosis, a disheartening situation. With a diagnosis of lung cancer, no matter how much money a person had, he or she would have traded it all to go back three decades to change smoking habits.
Individuals, cities, states, nations, and the world have a predictable quality: they do not value health until they lose it. The job of public health is to try and rewrite history before it happens. And that is not easy. Prevention is such a sensible approach that one thinks it should be in great demand. I had no idea how hard it would be in practice.
EIS Training
The EIS program developed some approaches that remain even sixty years later. Many officers were assigned to states, as that is where epidemic investigations often begin. Some were assigned to universities or other federal agencies, and many were assigned to the CDC headquarters in Atlanta or one of its branch offices. Regardless of assignment, all EIS officers returned to Atlanta for a week in April to present interesting cases and to participate in the interrogation of other officers presenting cases at the EIS conference. Rigid rules prevailed—such as no presentation longer than ten minutes, followed by ten-minute question periods—and have stood the test of time. But on Thursday nights, the rules relaxed. The outgoing class would perform a skit. It was a chance to ridicule the program, supervisors, and approaches, playing the role of jesters to the EIS. I always contended that this is when the EIS creativity was most in evidence.
An additional tradition developed. EIS officers remained in the club forever. An annual compilation was published summarizing the career of each officer, where he or she had lived, language abilities, professional expertise, and family information. With this EIS Directory, it was possible to quickly call on past officers for special problems that used their skills. Interestingly, many former officers returned for the EIS conference at their own expense, simply because the experience was so rich, and it provided an annual summary of public health problems.
Eventually, the target of investigations went beyond infectious diseases to include chronic diseases, injuries, natural disasters, nutrition, occupational and environmental problems, famine, and even homicides. When the military draft was formally lifted, the program began to recruit women, and now most classes are more than 50 percent female. While the original officers were predominantly physicians, veterinarians, and statisticians, diversity soon developed to include anthropologists, sociologists, and, indeed, most professions.
My first EIS conference in 1962 was a changing point in my life. Becoming an EIS officer was more than simply a new position. I liked the people. They were social activists, committed to solving the health problems of whole populations. The conference was stimulating, the presentations dealt with current problems, and the discussions were animated. After multiple interviews, I made my first choice, a state assignment to Colorado. It provided exposure to a spectrum of public health problems. The downside, of course, was not becoming a cutting-edge expert in a specific area, such as respiratory infections, diarrheal disease, or unusual pathogens.
June 30 was my last day as an intern, and my wife, Paula, and I drove from New York to Atlanta. Paula was quite pregnant, and our excitement was boundless.
July 1962 was my training period before going to Colorado. Paula and I got an efficiency apartment within a block of the famed Fox Theater in Atlanta, and I took the bus each day to the CDC. The lectures were compelling, and the afternoons were taken up with problems, such as discussing and solving previous outbreaks from the public health records, with information provided in the sequence it was first known to the original investigators. Statistical problems were presented, and I participated in a field exercise to collect information from a sample of houses visited in Atlanta, followed by analysis of the information obtained. It was all very practical.
As a fourth-year medical student at the University of Washington, I had attended a class in public health practice taught by Russ Alexander. He had been an EIS officer, and he used one of the outbreak presentations that he encountered at the CDC for my medical school class. It was an outbreak of pellagra, but that fact was not known to the students in the beginning. The seasonality, age distribution, rates by socioeconomic status, death rates, and the like all appeared to be caused by an infectious disease. So it was a surprise, during the discussion, to find that the cause of the outbreak was a nutritional deficiency. I was equally surprised, during the EIS course, to have the same problem presented. The difference was that I could ask great questions because I now knew the rest of the story. Some forty years later, I introduced Russ for a talk he was giving, and I could now thank him. By looking good during this exercise at the EIS course, I was incorrectly labeled as having keen insight rather than having average memory.
Throughout the course, the academic presentations were interspersed with real-time reports on ongoing investigations. Sometimes this was a call from the officer in the field or a summary of the outbreak investigation by the supervisor in Atlanta. When the training program was completed, Langmuir called us together to brief us on the latest news. He filled us in on the Sabin oral polio vaccine, a major advancement in the attempt to control polio. Given by mouth, it avoided the trauma of an injection and could be given by anyone. However, early evaluation was showing that it could also cause polio in some recipients or in the contacts of recipients. The CDC was still trying to estimate the level of risk but felt it might be a case of polio for every 1 million to 2 million children receiving the vaccine. Therefore, parents and providers should have this information as they made decisions on the use of the vaccine, Langmuir said. I had no idea at the time that this would be a contentious issue in Colorado and even more so in later years with the global effort to eradicate polio.
Assignment to Denver
When Paula and I departed for Denver in August, she was close to her delivery date. It is the hubris of youth and inexperience that made our traveling at this time possible. I had delivered twenty-eight babies during my month on OB/GYN, some months earlier, and so felt comfortable with the idea of delivering another one.
When we arrived in Denver, our first stop was Fitzsimmons Army Hospital to make an appointment at the obstetrics clinic. Only after that task was completed, did we check into a motel. We were still staying in the motel when Paula’s contractions started early one morning. On the way to the hospital, we stopped at a drugstore. I picked up a paperback titled Man-eaters of Kumaon by Jim Corbett. (Eleven years later we would go to the Corbett Park in India and from the back of an elephant attempt to see a tiger in the area where Corbett had been a game warden.)
The contractions continued and despite a scare with toxemia of pregnancy, David was born that evening. By 5 the next morning, Paula was up making her own bed. (Military hospitals have strict rules.) David’s first home after the hospital was a motel room, and his bed was a dresser drawer.
The EIS position in Colorado was close to ideal. My supervisor, Cecil Mollahan, was a bright and conscientious epidemiologist. He had an MPH from the Harvard School of Public Health and had grown up in Colorado, so he had an understanding of the state. Although Cecil could not always contain his affinity for alcohol, he was conscientious and would often start the day with a review of some of the problems I might encounter in the late afternoon if I alone would have to make the decisions. This unusual approach to supervising not only gave me greater responsibility and input from a savvy person but also gave me an insight into addiction in the best of people.
Within weeks I had investigated malaria in a person returning from Africa and a small outbreak of typhoid fever in Center, Colorado, which we traced to a grandmother who was a typhoid carrier. Center is located in South Park. To enter South Park from the north and suddenly see the vista of a flat valley at 10,000 feet, surrounded by peaks going up to 14,000 feet, was absolutely breathtaking. Who could have believed such beauty? This joy came despite being accustomed to seeing Mt. Rainier, the Cascades, and the Olympics during college and graduate school. I bought a book on ghost towns of Colorado, and on my many trips, I would make side visits to one or more of these remnants of mining days.
The medical society asked me to address them on the problems of polio vaccine. When I explained the risks of disease associated with the oral polio vaccine, I was surprised by the strong and repeated assertion that the risk was low and need not be conveyed to parents. I was being challenged on my assertion that although the risk was low, it was nevertheless real, and therefore had to be shared with recipients, even if that made immunization programs more difficult. To my surprise and relief, Gordon Meiklejohn stood up to defend my argument. Gordon was well respected and the head of the Internal Medicine Department at the University of Colorado Medical School. With his endorsement, medical society members changed their views and supported transparency with parents. Throughout my time in Colorado, Gordon was an interested participant in infectious disease problems. In later years, he became heavily involved in smallpox eradication and spent time in India as a short-term special epidemiologist.
The years in Colorado were good years. The work was interesting, and my appreciation of the CDC continued to grow as the people there were always available for advice and help in investigations.
Encountering Smallpox
I developed an interest in smallpox while investigating a suspected smallpox case in Farmington, New Mexico. Less than a year after entering the EIS, the April 1963 EIS conference led to an unusual opportunity. An announcement was made at the conference that the Peace Corps physician in India had to leave because of illness, and the Peace Corps was looking for a three-month volunteer to fill the position while they recruited for a new physician. I applied and spent a busy few weeks of orientation before departing for India.
Preparations included getting vaccination boosters and personal medications for malaria prophylaxis and common respiratory and gastrointestinal illnesses. I reviewed the most common medical problems encountered by Peace Corps volunteers. I traveled to Washington, DC, for interviews and briefings on India and the Peace Corps, bought books on the history of India, and reviewed papers on the disease patterns and medical care systems in the country. In recent years, the Internet has made it possible to collect any information you need after you enter a country. However, in the early 1960s, you had to predict what information you would want and take it with you. For the three months of my assignment, I was always scrambling to get information on diseases or treatments that I had overlooked in my preparations. And there is no way to prepare for the heat in India in May.
The Peace Corps was still new and finding its way. The Peace Corps country representative for India was Charles Houston. I had gone to India to do a job, not to acquire yet another unusual mentor. But acquire one I did. Although a cardiologist by background, Houston had vast interests, among them climbing K2, the second highest mountain on Earth (2). He was a hero to the climbing community because of his attempt, in 1953, to rescue a K2 climber with deep vein thrombosis during a storm. An exceptional team of climbers had been within striking distance of the summit but turned back without an argument to aid a sick person. The climber did not survive, but the very audacity of trying to execute this mission in a storm left climbers astounded. It was this leadership quality—including Houston’s ability to diagnose a problem, develop a response, get others to follow, and then show such tenacity that no one could shirk his or her responsibility—that made him such a successful leader in climbing, in medicine, and in inspiring Peace Corps volunteers in India.
In India, I could test my interest in tropical diseases and international health. At Houston’s urging, I visited hospitals, made rounds, treated volunteers, and arranged for sick Peace Corps volunteers to be hospitalized for major illnesses. I was invited into the homes of local staff and introduced to foods, culture, beliefs, and variety that make India one of the most compelling places in the world to work. Traveling by train to an unfamiliar area in order to locate a Peace Corps volunteer was an adventure in navigation. Before smartphones and GPS devices, one had to find someone who knew about an American in the area. Without fail, there was always someone who could direct me to someone who might know. Without advertising it, the CDC was showing itself to be a global agency, providing a pathway for those interested in global health.
While much of my time was spent on Peace Corps health matters, there were adventures. While visiting volunteers working on poultry projects in the Terai area of Uttar Pradesh, I learned of a new agricultural expansion that was taking place. While the term Terai originally referred to wetlands, it now described the plains bordering the Siwalik Hills. Parts of the Terai included recently deforested areas and thus were close to the wildlife of the forest.
Leaving the guesthouse where I had stayed overnight, I was told the volunteers were at the farm of a wealthy Punjabi farmer. The farmer’s yard contained about two dozen people, all talking about the man-eating tiger that had been spotted that morning. Corbett’s book Man-eaters of Kumaon had introduced me to both this area of India and the problem of tigers’ preying on people. Generally, only tigers with physical disabilities that make it difficult to hunt their regular game will prey on humans. Corbett is still remembered in India for killing dozens of proven man-eaters, often after they had killed dozens and in some cases even hundreds of people. A tiger had often eluded other hunters by the time Corbett was called in, and he would hunt alone, on foot, relentlessly tracking and finally killing the tiger.
The tiger now in question had killed several farmers in the area and was much feared. The group gathered that morning was drinking beer and developing a plan. (The beer, evidently, made the plan seem increasingly possible.) The Punjabi farmer had a number of large, Russian-built tractors and decided to have men with guns sit on the large fenders and stand on the various bars at the back of the tractors. The men would then traverse the fields, hoping to flush out the tiger, allowing one of the men a shot. I was invited to climb on one of the tractors to observe. I was too stupid and too curious to refuse.
With everyone loaded on the tractors, the signal was given to begin. The tractor drivers, accustomed to pulling loads, accelerated with the usual power, but with no load the front wheels left the ground, and everyone fell off the back of the tractors into a heap of bodies with guns sticking out of the pile. None of the guns fired, and everyone reassembled, and the tractors accelerated more gently. Fortunately, the tiger was not sighted, reducing the chance that the hunters would inflict serious harm on one another. Only then could we get to the real reason for my visit, which was to assess their health status, administer gamma globulin as a protection against hepatitis, plan for their next trips to Delhi, and collect information on the results of their poultry and agriculture projects to provide to Charlie Houston.
Colorado Cases
After three exhilarating months in India, a new Peace Corps physician arrived, and I returned to my EIS position in Colorado.
As with most people my age, I recall exactly what I was doing when I learned that President John F. Kennedy had been assassinated. I was working on hepatitis statistics in my Denver office. I went home and, for the next few days, joined the rest of the country in watching television and wishing it were possible to reverse time.
My two-year assignment in Colorado flew by. One undertaking involved following children in Colorado Springs who had been vaccinated with a killed measles vaccine. Jonas Salk had demonstrated that recipients of a killed polio vaccine developed antibodies. Then, Dr. Tommy Francis conducted a huge field trial on 1.8 million children with hundreds of thousands of volunteers to show, in less than two years, that the vaccine not only produced antibodies but also protected against the poliovirus. It was an exciting moment in medicine.
A few years later, there were similar hopes that a killed measles vaccine could protect against measles disease. A trial was conducted in Colorado Springs and indeed the vaccine elicited antibodies. Hopes were high, but then complications developed in some children if they were exposed to wild measles in later years. Some children were protected, but others developed what appeared to be an allergic response. While none of them died, it was clear that the vaccine could not be used on a mass basis. The results were published in an article I cowrote with Drs. Vince Fulginiti and C. Henry Kempe (3). The vaccine was dropped in favor of live measles vaccine.
Hepatitis outbreaks were constant in the 1960s, when there were no tests for the virus or antibodies. Cases were designated as A, B, or non-AB, based on clinical and epidemiologic findings. One memorable outbreak occurred in Minturn, Colorado, a small town near what would later be the Vail ski complex. An outbreak of hepatitis had frightened the community. There had been no deaths, but the lack of appetite, the yellow eyes, and the lack of energy led to concern. Some residents criticized the mayor, blaming him for a faulty water supply, which they felt had led to the outbreak. There was talk of impeachment.
In one of my more satisfying outbreak investigations, I collected information on the names of people with a history of hepatitis. As I was in a small town, I was able to interview many of them within a few hours. Hepatitis A, the most common type of hepatitis in Colorado, has an incubation period of two to four weeks but usually closer to four weeks. A common-source outbreak, such as a contaminated water supply, would have resulted in a cluster of onset dates about four weeks after the water supply became contaminated. However, if hepatitis A had spread from person to person, that would have supported disease-onset dates spread over an extended time period. It was quickly evident that the outbreak did not have a common source but was spreading through the community person to person. The grateful mayor’s reputation was saved. This appreciation is about as close as public health people come to the expressions of gratitude that personal physicians routinely get.
The Jet Injector
In 1964, I was part of a CDC group that went to Tonga to test smallpox vaccine by using jet injectors. The armed forces had pioneered the use of jet injectors for needleless injections. They had then developed a small injector that required no electricity. Between injections, the injector was cocked by means of a foot-operated hydraulic pump.
The question to be studied in Tonga was, what dilution of vaccine could be used in jet injectors to obtain comparable take rates to those obtained with a multiple-pressure technique? The multiple-pressure approach involved a drop of vaccine on the skin and multiple depressions through the vaccine with a needle tangential to the skin surface. If performed correctly, the needle was intended to prick the skin on the upstroke, providing a small injury for the virus to begin multiplication. Success rates varied widely, and even the same person would have better success on some days than on others. The jet injector was a marked improvement in both speed and ability to replicate results between vaccinators and even at different times with the same vaccinator. It also had the advantage of reducing the vaccine usage since one-tenth of a milliliter (300 doses per ounce) was injected between the layers of the skin (intradermal), thus avoiding the usual wastage of vaccine.
A half-dozen CDC people, led by Dr. Ron Roberto, tried different dilutions and then read the results days after the vaccinations had been given by inspecting the injection site for the signs of virus multiplication that led to a distinct ulcer or pustule. Tonga was an ideal site because it had not used smallpox vaccine for many decades. (Thus, there was no interference in interpreting vaccination results.) The bottom line was that the method was reliable and allowed more than 100 million smallpox vaccinations to be conducted in West and Central Africa only a few years later.
It was an idyllic assignment. Tourism had not yet reached Tonga so there were no commercial hotels. The population lived up to the name given by Captain James Cook: the Friendly Islands. Villages would often prepare feasts to thank us for vaccinating. We would sit on the ground with a long table of banana leaves containing pork, vegetables, fruits of all kinds—and an elaborate ceremony. A young girl would be placed at the side of each visitor to keep our banana leaves piled high with food. Our previous work in schools, where we were provided cafeteria lunches, paled in comparison.
Queen Salote, a tall woman of regal bearing, was adored by her subjects. She had been queen since 1918 and continued until her death in 1965, a year after our smallpox studies. She invited us for a reception at the palace, where she showed us a tortoise given to the King of Tonga in 1777 by Captain Cook on his third voyage. It had been living in the Royal Palace ever since and was written up, with a picture, in National Geographic. It was another brush with history.
My two-year stint as an EIS officer was ending, and I was making plans for more training before leaving for Africa to run a medical program. Reflecting on those years, there are several lessons that shine through.
The EIS experience provides one of the best imaginable relationships between federal and state agencies. The assigned person answers to a supervisor at the state but is available when needed for federal investigations. The state is provided with expertise and a direct channel to the CDC that it might not be able to have otherwise. The CDC, in turn, has a relationship that provides immediate access to health problems that it might not learn about so quickly were an EIS officer not on site.
Ped-O-Jet demonstration by Dr. William H. “Bill” Stewart (Epidemic Intelligence Service class of 1951), 1966. Photo from the CDC
State health officers offer another lesson. During my EIS assignment, Dr. Roy Cleere, the Colorado health officer, had been in the position for several decades and knew the state well. He became the interface between the scientific community and the political community. In later years, most state health officers were changed when a new governor was elected. The average length of stay in the position has now declined to three years or less. That the office is heavily based on politics rather than on public health has contributed to the weakening of the US public health system.
Then there is the lesson of informal networks. The short, two-year period in the EIS program provided an informal network, one that now encompasses more than 3,000 people. Throughout counties, states, academic institutions, foundations, federal agencies, and global institutions, finding a former EIS officer provides immediate rapport and common experiences. It is one of the strongest professional bonds I have experienced, exceeding that of medical school or other training programs. Fortunately, the approach is now being replicated in many countries.