Adventures of a Female Medical Detective
Page 1
ADVENTURES OF A FEMALE MEDICAL DETECTIVE
ADVENTURES OF A FEMALE MEDICAL DETECTIVE
IN PURSUIT OF SMALLPOX AND AIDS
Mary Guinan, PhD, MD
with Anne D. Mather
© 2016 Mary Guinan
All rights reserved. Published 2016
Printed in the United States of America on acid-free paper
9 8 7 6 5 4 3 2 1
Johns Hopkins University Press
2715 North Charles Street
Baltimore, Maryland 21218-4363
www.press.jhu.edu
Library of Congress Cataloging-in-Publication Data
Names: Guinan, Mary E., author. | Mather, Anne D., author.
Title: Adventures of a female medical detective : in pursuit of smallpox and AIDS / Mary Guinan with Anne D. Mather.
Description: Baltimore : Johns Hopkins University Press, 2016. | Includes bibliographical references and index.
Identifiers: LCCN 2015034008 | ISBN 9781421419992 (hardback) | ISBN 1421419998 (hardback) | ISBN 9781421420004 (electronic)
Subjects: LCSH: Guinan, Mary—Health. | Women physicians—United States—Biography. | Women in medicine—Biography. | Epidemiology—Case studies. | BISAC: MEDICAL / Public Health. | MEDICAL / Infectious Diseases. | BIOGRAPHY & AUTOBIOGRAPHY / Personal Memoirs.
Classification: LCC R692.G85 2016 | DDC 610.82—dc23 LC record available at http://lccn.loc.gov/2015034008
A catalog record for this book is available from the British Library.
Special discounts are available for bulk purchases of this book. For more information, please contact Special Sales at 410-516-6936 or specialsales@press.jhu.edu.
Johns Hopkins University Press uses environmentally friendly book materials, including recycled text paper that is composed of at least 30 percent post-consumer waste, whenever possible.
TO JOAN, BRENDAN, AND CHRISTOPHER
CONTENTS
Acknowledgments
Introduction
ONE
My First Outbreak Investigation
TWO
Something to Believe In: Operation Smallpox Zero
THREE
A Gift of an Elephant
FOUR
Dr. Herpes
FIVE
Healthcare Workers and Enemy Information in a War Zone, Pakistan, 1980
SIX
An AIDS Needlestick at a Rundown Hotel in San Francisco, 1982
SEVEN
ACT UP Acts Up at CDC over the Definition of AIDS for Women
EIGHT
The HIV-Infected Preacher’s Wife
NINE
Few Safe Places
TEN
Expert Witness for John Doe, the Pharmacist, 1991
ELEVEN
The Milk Industry Challenges CDC over the Source of a Listeriosis Outbreak
TWELVE
On Getting AIDS from a Toilet Seat and Other STD Myths and Taboos
References
Index
Illustrations follow page 62.
ACKNOWLEDGMENTS
TO LIBRARIANS Xan Goodman (Health and Science Librarian, University of Nevada, Las Vegas); Terry Henner (Head of Outreach Services, Savitt Medical Library, University of Nevada School of Medicine), who enthusiastically answered every one of my multiple requests for help in finding references and out-of-print books; and Mary Hilpertshauser (Historic Collections Manager, David J. Sencer CDC Museum), who tracked down photos and historical information that were invaluable and is now preserving the history of CDC’s contribution to smallpox eradication.
To all my former CDC colleagues who helped me during the writing of this book, especially Harold Jaffe and James Curran, with whom I first worked in the sexually transmitted diseases unit and then transitioned to investigate the emerging AIDS epidemic; Claire Broome, a valued friend and collaborator on the Listeria dilemma; Mary Serdula, who shared the assignment in Pakistan and provided photos; Eugene McCray, who led the nationwide “needlestick” study and helped me find all the relevant papers; Vince Radke, for keeping “smallpoxers” connected; Walter Orenstein, with whom I was assigned to India and shared the joy of discovery of our careers as medical detectives; Helene Gayle, who gave me sage advice I badly needed at various times in my life and encouraged me to write; Verla Neslund, my CDC lawyer, who ably helped me with many tricky legal issues; Wanda Jones, who helped with my testimony on the Listeria case; and of course Bill Foege, whose leadership and vision continue to inspire me even after forty years. To my coauthor Anne D. Mather, who was the managing editor of CDC’s weekly newsletter, the MMWR, when I first met her in 1974, and who edited its article that reported the first cases of AIDS in 1981. Without her persistent encouragement, historical knowledge, good humor, and creative editing, this book would not have been written.
To Gary Wormser, my medical school classmate, with whom I worked when investigating the early AIDS cases in New York and who had the courage to testify in support of John Doe’s employment despite the risk to his career. To the anonymous reviewers who convinced Johns Hopkins University Press to publish the book. To the fantastic efforts of JHUP staff: Kelly Squazzo, first acquisition editor; followed by Robin Coleman, who enthusiastically promoted the book and went to extraordinary measures to shepherd it through the system; Isla Hamilton-Short, who was consistently there, especially during the editor transition, to troubleshoot innumerable issues while remaining calm and pleasant; editors Juliana McCarthy and Ashleigh McKown; and our publicist, Kathryn Marguy.
A special acknowledgment to the late Randy Shilts, one of my heroes, who in 1981, during the early epidemic, dedicated his column in the San Francisco Chronicle to AIDS, when most other journalists and newspapers avoided AIDS coverage; who wrote the definitive history of the emerging epidemic in And the Band Played On, one of the most important books of the twentieth century; and who supported the closing of gay bathhouses in San Francisco, despite vilification by the gay community, because he knew it was the right thing to do to reduce the spread of AIDS.
And finally to my family, especially my niece, Kate Guinan, whose wonderful art enlivens the back cover and interior of the book; my sister Joan Lunney, who when she read my first story told me to “get an editor”; and to my life partner Christopher Horton, who never failed to encourage me.
ADVENTURES OF A FEMALE MEDICAL DETECTIVE
Introduction
MANY people have told me that they wished they had known about medical detectives when they were deciding on a career. Until recently, few young people were exposed to medical detective stories or to undergraduate experiences that might have led them to a career as a medical detective, that is, a career in public health.
Epidemiology is the tool of the medical detective. It is the branch of science that studies the patterns, causes, and effects of health and disease conditions in defined populations. The worldwide symbol of field epidemiologists is the “hole in the sole,” evidence that we have worn out our shoes tracking down vital clues.
Until recently, courses in epidemiology were usually available only in advanced degree programs of medicine and public health. Now, fortunately, such courses are part of a growing number of American universities’ undergraduate programs in public health.
Because public health or population health is not well understood by the American public, I wrote these stories to help readers better understand and value the public health system that exists for the protection of the nation’s health and for the prevention of disease and injury. My purpose also was to show the work of medical detectives as interesting, often fascinating, and personally rewarding, and to encourage young scient
ists to enter a field where dedication to improving the lives of others has its own reward.
For this book, I tried to follow the format of the Sherlock Holmes stories by focusing on “cases” in which I was part of the investigation. Unlike Mr. Holmes, however, I was never the most important leader. A medical detective has a small part in a team effort, usually a very large team. Perhaps millions participated in the worldwide smallpox eradication effort, and certainly the investigation of the AIDS epidemic involved hundreds of thousands of scientists and public health and healthcare workers around the world.
Another difference between Sherlock Holmes’s stories and those of medical detectives is that Holmes almost always solved the mystery. After more than thirty years of “investigation” of the AIDS epidemic, the control of this infection is still a mystery. We have neither an effective vaccine nor a cure.
Nor have we “solved” the Ebola epidemic, ongoing in West Africa since 2014. The Ebola virus is especially worrisome because of its relative ease of transmission after exposure and its high mortality rate. One can only be in awe of the many dedicated workers who have volunteered to serve in such a dangerous environment. Not the least of these are the medical detectives who collect clues, analyze data, investigate suspected cases, and carry out their public health mission.
ONE
My First Outbreak Investigation
IT WAS the evening of August 9, 1974. I was sitting at a bar in Atlanta, Georgia, watching President Richard M. Nixon resign from office. My rented, furnished apartment was nearby, but it had no television, and I did not want to miss seeing this historic event.
Also nearby was the Centers for Disease Control (CDC),* the only federal agency with headquarters outside of the Washington, DC, area, and my new employer of several weeks. Since the first week of July, I had been taking an intensive course in epidemiology and biostatistics. The course was my official introduction to the Epidemic Intelligence Service (EIS), a two-year epidemiology training program for which CDC was justifiably famous. I was lucky enough to be among the forty-five EIS officers, as we were called, selected for the EIS class of 1974. Of the thirty-nine physicians in the class, I was the only woman. In the early seventies, less than 10 percent of medical graduates in the United States were women. In the internal medicine training program that I had just completed, I was the only woman.
EIS officers are on call twenty-four hours a day to respond to requests for CDC assistance in the investigation of disease outbreaks or other public health emergencies. Each officer is matched either with a branch or program at CDC or with field stations, such as state or local health departments. I was matched with the Hospital Infections Program at CDC.
I did not have to wait long for my first outbreak. On August 28, my supervisor, Dr. Walter Stamm, came to my office and told me that a branch of the military had called CDC to request help with an outbreak of Pseudomonas sepsis (a bacterial blood infection) in the intensive care unit (ICU) of a large military hospital. As far as anyone could remember, this was the first time that the military had requested help from CDC. I had been chosen to go, and I was told it was to be kept confidential. Arrangements were being made for my travel orders and flights while I spoke with Dr. Stamm and other colleagues, who gave me information about the organism causing the outbreak and other briefing materials. Then I was told to go home, pack a bag, and be ready to leave on a plane later that afternoon.
In those days, airport security was minimal, and one could just enter the airport and proceed to a flight without being subject to screening. Upon arriving at the airport, I ran directly to the gate with my paper ticket and was the last passenger to get on the flight.
During the flight I reviewed my orders. I was a member of the Commissioned Corps of the Public Health Service, a uniformed service presided over by the US surgeon general. The corps headquarters in Washington issued our orders. Although a uniformed service, CDC officers at that time were exempt from wearing uniforms. (I believe one reason was to keep EIS officers relatively anonymous when they were investigating outbreaks.) So I was wearing plain clothes on the flight.
When the plane was preparing to descend, the pilot announced that landing would be delayed because horses had escaped from a nearby ranch and were on the airport runway. A small plane had collided with some of the horses, and we could not land until the runway was clear. We circled for more than two hours. Finally, we landed sometime after midnight.
A weary military escort team was waiting for me with a sign that read “Dr. Guinan, CDC.” I walked up to the uniformed four men and one woman and identified myself. The men were clearly shocked that “Dr. Guinan” was a woman, and they were apologetic. They had not known that “CDC was sending a woman.”
The everyday dress code for EIS officers was casual at CDC; some even wore jeans and t-shirts to work. Because I had had no time to change, I was wearing what I had worn to work that morning—a long-sleeved plaid shirt, black slacks, and Earth shoes, comfortable, sensible shoes made in Sweden that had heels lower than soles, supposedly good for the back and spine (they weren’t). I wore no makeup, and my hair was tied behind my head in a long braid, a hairstyle that my colleagues told me gave me the appearance of being a “hippie.” (Hippies were associated with the peace movement and the anti–Vietnam War marches that had torn the country apart. President Nixon had ended the war only a year earlier.) I wondered whether I should have given more thought to what I wore.
The uniformed officers took me to the base where the hospital was located. The base commander had closed the operating room and had called an “all-hands” meeting of healthcare personnel for the next day at 7:00 a.m., and I was asked to attend. The female member of the escort team was the hospital infection control nurse, Sarah,* one of a small number of woman officers at the hospital. She had arranged for me to stay off base in her home during my investigation. This was a great advantage for me: I did not have to worry about a place to stay, and I also had the infection control nurse as an ally in the investigation. Sarah told me that she was the only member of the escort team who knew beforehand that I was a woman, and she had not told the others. We laughed about their reaction.
The next morning I arrived for the meeting at the auditorium, which was packed with well over a hundred uniformed personnel. I sat in the back and noted that I was the only person not in uniform. The base commander was the speaker. He discussed the hospital’s serious situation. It had eight cases of Pseudomonas blood infection in patients in the ICU, and the surgical suite had been closed, except for emergencies. Although the base commander did not mention it, many of the people who were ill were high-ranking officers. In fact, CDC had advised me before I left that one of the possibilities that the staff on the base were entertaining was that the blood had been deliberately contaminated with the Pseudomonas organism. Was someone trying to kill the officers? This concern was one of the main reasons that the investigation was to be kept confidential.
The base commander reinforced the seriousness of the situation by stating that it was the “first time in history” that a military hospital had called in an outside agency for assistance in an outbreak investigation. Furthermore, he said, “Let me tell you how fast CDC works. Yesterday we called CDC, and before 7 p.m. their expert was on his way here, and he is in the audience right now. Will he please stand up?”
I didn’t. I did not want to embarrass either the base commander or myself. (Had someone deliberately not told him that I was a woman?) After looking around and seeing no one standing, the base commander finished his talk by asking for cooperation in the continuing investigation and stating that the operating room (OR) would remain closed until the source of the contamination was identified and eliminated.
After the meeting, I was introduced to the commander, who thanked me for coming. Then Sarah introduced me to the director of the infectious diseases unit and to many of the surgeons, nurses, and other personnel involved in the care of these case-patients.* The most frequent questio
n I was asked was how long I had worked at CDC. Each time I answered “a while.” I was worried about CDC’s and my credibility if word spread that the CDC expert was not only a woman but also one who had been working at CDC for only several weeks.
Before my arrival, the hospital infection control team, led by Sarah, had undertaken an intensive investigation to find the source of the contamination of the patients’ blood. Over the next several days, I reviewed all the data that they had collected. I interviewed a number of the surgeons and nurses to get their opinions on what was causing the blood contamination. Some expressed concern that the OR environment might be contaminated. I asked for a tour of the now-closed OR, where most believed the blood contamination had occurred.
It was in a very old building, and the OR was large, with extraordinarily high ceilings. The cleaning crew described how they cleaned the OR after each surgery and pointed out that the ceiling and the highest part of the walls near the ceiling were not cleaned daily. The crew also saw flies occasionally buzzing close to the ceiling and indicated that the flies were quite difficult to eliminate. The cleaning crew asked for my opinion on whether these could be factors. I did not know, so I wrote in my notes to do a review of the literature on infectious outbreaks in ORs. Were any due to environmental contamination?
We reviewed blood bank procedures. All coronary bypass patients receive multiple blood transfusions. I was guided through the process of how the heart-lung bypass machine was connected to the patient and was told how many units of blood were used on average for each patient undergoing coronary artery bypass surgery. After the first few cases of sepsis had occurred, Sarah had begun culturing the blood from the blood bank before its use in the patients. All these cultures were negative. Her investigation found no evidence that the blood was contaminated before use.