Tales From The Hinderland ; The Education of a Public Health Officer

1. Tales From The Hinderland;The Education of a Public Health Officer A Scott Lea, MD University of Texas Medical Branch

3. P.L. Panum(1820-1885)

4. Faroe Islands (Denmark)

5. FAROE ISLANDS

6. 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

7. 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

8. 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

9. Waco-McLennan County

10. Waco, Texas

11. 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

12. 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

13. 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!

14. 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.

15. 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

16. Frank Gentsch

17. ‘Bear Fever’

18. Measles

20. Health Authority for Waco-McLennan Health District(1983)

21. 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

22. Health District Function • Administration • Vital Statistics • Environmental Services • Surveillance • Nursing • Prenatal services • Dental • Immunizations • TB control • STD’s • WIC (Pediatrics) • HIV Services

23. Skills • Infectious Disease Training • General Internal Medicine Training • Political Skills • Celebrity Status (Interviewing Skills) • Epidemiology (Public Health Training) • Negotiation Skills • Legal skills • Patience • Genealogy • Cultural/Diversity Communication/Education

24. Communication and Marketing: HIV in Central Texas • HIV in Central Texas • Group A Beta-Hemolytic Streptococcal Disease

25. Communication And Marketing – HIV, 1985

26. 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

27. 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

28. Microwaves on the Brazos - 1989

29. Investigating an Outbreak • Case Definition • Index Case • Primary Case • Secondary Case • Suspect Case • Registry • Diagnosis Verification • Case Finding • Incidence • Prevalence • Population • Case Analysis • Exposure • Cause and Effect • ‘Next Neighbor’ - The Poisson Distribution • Common Source vs Serial Transfer

30. 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!!!!!!!!!!!!!!!!!!!!!!

31. Cultural/Diversity Communication/Education and Negotiating Skills • Tuberculosis Outbreak – High School, 2000.

32. Infectious Disease E coli 0157 – Baylor, 1996

33. Legal and Negotiating Skills Herpes encephalitis

34. Legal Skills Meningitis – Baylor University - 2000

35. Legal Skills - 1993

36. 2004 – On to Academia