Tales From The Hinderland;
The Education of a Public Health Officer
A Scott Lea, MD
University of Texas Medical Branch
P.L. Panum
(1820-1885)
Faroe Islands (Denmark)
FAROE ISLANDS
Measles on the Faroe Islands
1846
• No measles in 65 years on the Faroes
• Panum dispatched to study the epidemic and provide medical support by
the Danish government as a medical student
• 6000 of 7782 residents affected – in some communities 19/20 were
affected
• Observations were made on the people, and village to village spread
involving 52 communities (Each settlement was an isolated community in
which the disease could be studied)
• His thesis is the first and most complete description of a disease in the
history of epidemiology ; he writes the classic ‘Observations Made During
the Epidemic of Measles on the Faroe Islands in the year 1846’ published
in 1847
Measles in the Faroe Islands
(1846)
• ‘the circumstances under which the disease was observed were so
favourable that similar ones were rarely, if ever, presented to an
observer.’
• No miasmatic origin – it spread man to man!
• Incubation period was 13-14 days
• Begins in a community when the primary case is in the eruptive
stage
• Could not fined a single case traceable to exposure after the
disappearance of the rash
Measles on the Faroe Islands
(1846)
• Describes the lasting immunity – 98 ‘old persons’
escaped the disease
• Has difficulty excluding the part fomites play in
transmission of the disease
• Not a Zoonotic disease
• Thought it spread thru the ‘gaseous emanations’
of the human
Waco-McLennan County
Waco, Texas
Waco-McLennan County
(1982)
• Waco has a population of 100,000
• McLennan County has a population of 187,000
• Central Texas has a population of 500,000 to 1,000,000 (Ft
Hood, Killeen, Belton, Temple, Waco)
• Education and Agricultural community
• Baptist community
• Home of Dr Pepper, Snickers, Skittles, and 3 VAMC’s
Waco McLennan County Health District
(1982)
• Run by a retired military colonel who had complete
control of the health department. He was a general
practitioner
• Pragmatic, common sense city manager who was a
master at politics
• Enlightened mayor who was a lawyer and friend of
mine from college days.
• Best nursing service in the city
McLennan County Medical Community
(1982)
•
There was no Hepatitis B in Waco, Texas (but the hospitals did not test for it)
•
One hospital had no microbiologist and no instrumentation; the other hospital had an infection
control committee run by a medical technologist; ‘quality assurance’ was just beginning to get
started
•
The chief pathologist at one hospital couldn’t spell or pronounce ‘Chlamydia’; the pathologist at the
other hospital admitted he knew nothing about microbiology and wasn’t interested in modernizing
as long as the other hospital had facilities for ‘those kind of problems’
•
Town had many ‘family doctors’ and ‘GP’s’ who were World War II veterans with only GI, Cardiology
and Nephrology represented as medical specialties: One hospital did all of the medical specialty
procedures (endoscopy, dialysis, and catheterizations) and the other hospital did OB/GYN, and
surgical procedures. Most of the physicians thought they knew everything, and all of the older
physicians new very little about teamwork.
•
‘If you have a “sick patient, you need to get them out of town!’ – Dallas or Houston, not Temple!
•
‘Good Old Boys’ network and it extended into the other areas of the community – like the business
community and legal community and the clergy!
McLennan County Medical Community
(1982)
• Baylor University pushes the community to modernize itself – student
pressure, academic freedom and discourse, and Turnover
• Hospitals were having to compete with Scott and White, …………30 miles
south!
• Media was becoming more aware of ‘medical stories’; No computers,
internet., media, or cell phones
• Business was just becoming aware of the medical community as an
economic force
• Influx of young medical and surgical specialists
• Hospital administrators and Community leadership was sincerely
committed to improving the community on all levels.
A. Scott Lea, MD
• Baylor University and Temple High School Graduate
• Father was a well-known dermatologist in the community
• Well-trained in internal medicine and infectious disease (not
epidemiology or public health; no legal or political insight)
• Not Baptist, but schooled by the Baptists and a Baylor Graduate
• ‘Liberal minded’ and outspoken; I had the first word processor in
Waco
Frank Gentsch
‘Bear Fever’
Measles
Health Authority for Waco-McLennan Health District
(1983)
Waco-McLennan County Health
District
• County has a mandate to put aside a certain
amount of it’s budget for health care (10%)
• City and county came together and the city funds
the health department while the county funds
indigent care
• Department has a good ‘feel’ for the community
because everyone knows one another
Health District Function
• Administration
• Dental
• Vital Statistics
• Immunizations
• Environmental Services
• TB control
• Surveillance
• STD’s
• Nursing
• WIC (Pediatrics)
• Prenatal services
• HIV Services
Skills
• Infectious Disease Training
• Negotiation Skills
• General Internal Medicine
Training
• Legal skills
• Political Skills
• Patience
• Celebrity Status
(Interviewing Skills)
• Genealogy
• Epidemiology (Public Health
Training)
• Cultural/Diversity
Communication/Education
Communication and Marketing:
HIV in Central Texas
• HIV in Central Texas
• Group A Beta-Hemolytic Streptococcal Disease
Communication And Marketing –
HIV, 1985
Group A Streptococcal Reporting - 1995
“Events that do not occur, do not
attract attention” - E.A. Winslow
“If public health is successful, nothing
happens.” - Bernard Turnock
Vital Statistics
January, 1990 – 19 people died in McLennan County with ‘Influenza’ as the
‘cause of death’
Between 1990 and 2000, only one fatal case of Cervical Cancer in
McLennan County
Microwaves on the Brazos - 1989
Investigating an Outbreak
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Case Definition
Index Case
Primary Case
Secondary Case
Suspect Case
Registry
Diagnosis Verification
Case Finding
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Incidence
Prevalence
Population
Case Analysis
Exposure
Cause and Effect
‘Next Neighbor’ - The
Poisson Distribution
• Common Source vs Serial
Transfer
Outbreak - Caveats
• One can create an outbreak by suddenly counting
a disease that has not been counted previously
• One can create an outbreak with a change in
– Technology
– Case definition
– Diagnostic capability
• One can create an outbreak if one makes the
wrong diagnosis!!!!!!!!!!!!!!!!!!!!!!
Cultural/Diversity Communication/Education
and Negotiating Skills
• Tuberculosis Outbreak – High School, 2000.
Infectious Disease
E coli 0157 – Baylor, 1996
Legal and Negotiating Skills
Herpes encephalitis
Legal Skills
Meningitis – Baylor University - 2000
Legal Skills - 1993
2004 – On to Academia