Recap: Agent 69 - Top Secret Dodo

Agent 69 - Top Secret Dodo

I am calling in a prescription for a pair of Ruby Red Slippers

Ever had to ask yourself: What am I doing here? or What was I thinking? or Where was my brain when I decided to do this?

These are my thoughts as I round up with the dead and with the live PhD.'s and the veterinarian, who are charged with the task of extracting medical information from death records. Except maybe for the veterinarian, the PhD.'s have never seen a medical record and what I spent fours years doing, these PhD.'s are expected to acquire in the span of two days, in the name of epidemiological research. They argue that the methodology is the same so it really doesn't matter if you are studying the epidemiology of frogs laying eggs or the incidence of cancer in textile workers working in the dye industry, it is all the same. There will always be limitations to the data as a result of data gathering but the data always speaks the truth. Except when you have PhD.s extracting information from medical records. You see, you don't really have to be accurate in data gathering, so I am told. You just have to be consistent and make sure that there is very little inter-operator variability. In other words, we could all be making mistakes just as long as we are making the same mistakes. It sure makes me view these CDC reports with a little more skepticism.

I am trying to keep an open mind, but having been scarred by previous encounters with this elite force the government is training to be the health leaders of tomorrow, I am wary.
We settle in for yet another day of meeting the dead when a question is brought up about depression and major depression, which I am only half listening to as the stories I am reading are quite enthralling (it is too bad I had no time to thumb through the pictures). Geez, I sucked at psych, even though I enjoyed the rotation. I remember a lot of psychiatric diagnoses had to do with time; six months of this; two years of that, all quite seemingly arbitrary, as is most of psychiatry. But someone has to make the rules up so the rest of us cattle can follow. So I say:

"I think it has something to do with time, something like two years?"
"No, you're wrong, that's dysthymia," PhD. number 1, young blond chick with a nose like Barbara Streisand's, huffs.
"We can look it up," I ventured, which is the absolute wrong thing to say to the PhD.
"I'm a clinical psychologist and we don't have to look it up!" She squeals.

Well, pardon me for expressing an opinion, but we are all not god, such as yourself, and know everything to know about everything in the world. I will leave you to make your own conclusions about PhD.'s level of self confidence. I humbly quelled the situation by saying:

"I sucked at psych and my total of six weeks of psych exposure in no way measures up to your six years of PhDeityism," which was the truth. Too much ego in a little room and too much ego in an organization for me to feel all warm and fuzzy about.

I am reminded of my flight into West Virginia. I was supposed to meet Ms PhD. at the airport because we were going to share a ride into town. This was a cost savings for the government for why pay for two car rentals when you can pay for only one? I've never met Ms PhD. and so I text her a message on my secret agent cell phone but she never replies. I figured I would find my own way. The flight into WV, outbound from Dulles, Washington, DC, was in a two-engine propeller plane. There were about 10 people on the plane. I wasn't too concerned about finding Ms PhD. After traveling alone for the most part of my life, I think I am capable of handling a ride to the hotel. Besides, I was sure we would bump into each other sometime. I settle in for a short 1 1/2 hour trip and started reading my Micheal Crichton novel about sneaky scientists driven by political agendas and skewing data, when I hear this conversation (it's a very, very small plane):

".....so why are you visiting West Virginia?"
".....I'm a government scientist working for the CDC!"
Despite the props outside going at a loud whir, I hear the conversation distinctly. So did the rest of the other nine passengers. This piece of information, I'm sure, was meant to be heard.
Well, I guess I found Ms PhD.

This should have been my cue that I was going to want something stronger than moral support for the next 12 days.

The second day came and we were to meet the Lead Investigator in his home territory at the Health Department. We are, of course, stopped by security, having no clearance to enter the building. Ms PhD. was again, huffy, wanting to know why we were waiting in the lobby; if lead investigator knew we were there and she asks me if I had his cell phone number, which I did. Prior to the trip, I had programmed phone numbers into my secret agent cell phone. I decided to try him at work first, just in case he had arrived early. So I pull it up and hit send.

"Division of homeland security, Nancy speaking, how can I help you?"
Homeland security? Opps, lead investigator must have given me the wrong number. After an unnecessarily lengthy conversation with Nancy from Homeland Security, I get the correct number for the health department. Meanwhile, Ms PhD. was listening in and did not spare me her comments:

"What is she doing? Who is she calling?"
Look, Ms Brainsinyour ass, I have lived long enough and have had real work experience in the land other the Oz, and know how to conduct a telephone conversation. In fact, I knew how when I was like six and really didn't need to go to PhD. school to learn how to politely ask for someone over the phone or to apologize if I dialed the wrong number.

What am I doing here?

I decided this wasn't worth the fight. I have been wise now, after all these years, to realize that some fights are just better left alone because it would create too much aggravation. I happen to prize my sanity.

So we muddle along. Day three comes and I have been wanting those Ruby Red Slippers secretly now since the first day. Instead, I treated myself to beer, wine, greasy hamburgers and fettucine alfredo. Back at the M.E.'s office, we plod along. There is now talk about liabilities and blaming. How can dumb people get a hold of prescription narcortics and benzodiazepines? Well, a doctor had to prescribe it. Doctors must not know what they are doing! Ms PhD. exclaims.

"I've never seen so many made up diagnoses in my life!" PhD. Barbara Streisand says. "Explosive personality disorder, no such thing!" Strangely enough, I come to find an ICD-9 (International Code of Diagnosis) code, 301.3, for it. These are codes physicians use so they can get billed for services. In Oz land, the world according to PhD. Barbara, however, Explosive Personality Disorder is made up, much like the entire Oz land is made up.

And then, there are comments about a doctor did this? and a doctor did that? Geez, why don't we just fry doctors at the stake? Better yet, why don't we make the world safer by having PhD.'s prescribing medications? Then, when I could not bear it any longer, I say this:

"We have no way of determining what the circumstances facing these various doctors were, or how they rationalized to write prescriptions for these people who had died as a result of not following their doctors' orders and taking too many pills at one time, or acquiring prescription medications illegally. No physician can deny pain medications to someone complaining of pain. That's unethical. At the same time, you cannot question that someone who tells you he is suffering from pain is truly suffering from pain. These judgment calls are easy to make in the comfort of an air-conditioned office when there is no real world experience of what a physician actually goes through."

The veterinarian concludes that I am being defensive.

How can I not while they are vilifying the profession I am about to enter? If I had said something equally offensive about veterinary medicine, about clinical psychology, about whatever it is the other PhD.'s special line of research is, I have no doubt that all of them would have reacted the same way. I continue to say:

"I am no scientist but you people are. You are here to investigate the circumstances in which these unfortunate 360 people met their deaths, all by choice, I may add, while taking prescription medications and then some and out of this investigation, a witch hunt may ensue and other studies will be done to see how we can 'better the system' and out of these studies, recommendations will be made that will affect me as a physician ten years down the road! And there are so many holes, what you call limitations, in your data gathering that I am supposed to believe that all these recommendations will be based on some semblance of truth?"

Oh, the data will affect all of us, they say. Which all of us are they talking about, the people stuck in the Ivory Tower of Research, who have no real world experience of the medical world or the real world, or the physicians in the trenches who, day in and day out, fight the battle of being a good physician despite the surmounting mountains that daily affronts him? Who does it really affect?

Where was my brain when I decided to do this?

After the gun smoke clears and the dead are counted, I was reassured that there are many checks and balances to ensure that research is conducted to accurately reflect the truth. There are committees that come together and I was told that the opinions of the people who will be affected by these recommendations are sought. I give an analogy and, in a nutshell, summarize all these ideas floating around in my head:

There is a proposed hospital to be built. The architects and the engineers come together and they construct this very beautiful hospital that wins awards for its beauty. However, the structure is completely non functional. There are doors that open into work spaces, entrances that lead you round in circles, stations that are built, making the staff totally inaccessible to the patients. No one bothered to ask the people who will actually be working in the hospital if things made sense, or just looked pretty.

On my last day at the M.E.'s office, I meet PhD. number 2's boss. The meat and potatoes of this whole venture is the data. Like a piece of bloody, red meat, it will be at the center of a feeding frenzy as people get a piece of it and claim their stakes at, the coveted, "authorship" of papers that will be generated as a result. He makes a special trip from Atlanta to see how the extraction process is coming along. He is a very nice gentleman. I come to find out that he had gone to medical school with no idea what it meant when someone said "preventative care", enrolled in the same elective I am currently enrolled in, goes on to residency in primary care, and then on to another residency in preventative medicine, joins the EIS program and when he completed it two years later, he finds a job at the CDC. This man has never practiced medicine a single day in his life. Remember Skinny man? Same story. And then I come to learn that Ms PhD. went to high school, entered college, went on the grad school, is now in the same EIS program, having had only one year of internship where she was required to see patients and no breaks in between her academic life. This trend bothers me.

What was I thinking?

Are there real world people around or is it all filled up with people who have never lived beyond the pearly gates of Institution, think themselves to be deities of some kind or other, assume all people are stupid and need to be advised and given recommendations on how to live their lives? What happened to the "art of medicine" or the "trust your clinical judgment" slogans they chant and teach all through one's medical career? Apparently, if these M.Deities and PhDeities have their way, the art of medicine and one's clinical judgment would be squished into a recommendation they have the Tin Man (no heart) and the Scarecrow (no brains) come up with.

I want to go home, I want to go home, I want to go home.

These Ruby Reds seem to be defective. Probably made in China. I will have to take it up with headquarters.

I See Dead People

While the Whoop is dying down and winding up and all there is, is a distant coarse bark in the distance, I get a call from headquarters. All that needs to be done in Mississippi is done. The rest of the work can be (and is usually) finished back in Atlanta. There was another more pressing issue that needed to be addressed: the very Top Secret task of investigating an outbreak of pharmaceutical related deaths.

My secret agent services were once again in demand.

So, I make it back to Atlanta, laundered my underwear, and on Labor Day, swiveled back to the airport, once again outbound, traveling on government business.

Yes, there is a DEATH outbreak in West Virginia (you heard right) and I get to go find out why a subset of West Virginians have inadvertently decided to end their lives by O.D'ing on prescription medications.

Reporter: “As a spokesperson for the CDC, can you describe the case we have here?”
Me: “We seem to have a case of bonafide Death in West Virginia, Death of the truly moronic kind.”
Reporter: “Is it contagious, can we catch Death?”
Me: “Yes, unfortunately, you can, especially if your mother or father or friend had caught it first. What do you expect when you marry your first cousins and are related to your uncle by marriage?”

I should never be allowed to speak on behalf of the CDC. Thank goodness I am just small fry.

Here is a story of how one catches Death…

Nestled in the valley, surrounded by the Blue Ridge Mountains(and no, John Denver was not making it up), was the Medical Examiner’s office, which happened to be on the wrong side of the railroad tracks. Here, things are more run down and Starbucks is nowhere to be found. The nearby Kroger’s (grocery chain) doesn’t carry any ethnic food in their freezer section and I’m the closest thing to tiki paneer in a 100-mile radius. Charleston, the capital of WV, has the feel of Julesburg, Colorado. Things go to sleep past 5 pm and you will find no one walking around after eight. It is hard to believe that 3 million people live in WV.

I am thankful my urge for adventure was chained up somewhere between Atlanta, Georgia and Philadelphia, Mississippi. I ventured as far as the downtown corner, quaint bookstore. I really wanted to snoop around the middle-eastern café/grocery store one block from the coffee shop because I was thinking about stuffed grape leaves, but decided that prudence was the better entity to seek advice from, rather than my hunger. It was only 6 in the evening and although not totally deserted, Charleston still had some unsavory characters floating around. Or was it just my prejudice forming as a result of being surrounded by know-it-alls who constantly pigeon-hole people in order to better characterize them and predict their behaviors?

The M.E.’s compound was forged like Fort Knox. You needed a badge to get in and a badge to get out. It was surrounded by a chain-link fence with barbed wire. There were security cameras everywhere.

These folks are dead, people. But I guess the dead have the right to have their organs secured lest some desperate folks attempt to separate them from their owners and sell them on the black market to earn a quick buck.
This is the right neighborhood for that.
Macabre.
I suppose it is also for the safety of the very few people alive past 5 pm who are on call to receive the dead.

Our first task was to go through a huge book the people at the ME’s office call ‘The Bible’, filled with names of people who have met their last obligations on earth, to obtain their death certificate numbers. There were pages and pages of names and pages and pages more catching the Death from an overdose of prescription medications.

Peter Steeley, DC #06-092
Oh, Peter is sure steely now.

Cycy-Jo Sparks, DC #06-153
Cycy-Jo is enjoying the sparks down below.

Daniel Bob Baker, DC #06-1046
Poor Dan Baker baked his last batch of cookies.

Billyjo Bob Flowers DC # 06-054
Billyjo Bob ain't planting no flowers no more.

I couldn’t help but have a little fun. What’s life when you can’t have a little fun with death? As we plough on and we are actually reading the ME's autopsy reports along with the death investigator reports (real-life CSI people!), I am getting the sense that the majority of these folks 1) like their drugs and 2) are not the brightest tool in the shed.

Case in point: obese guy does a little cocaine and then proceeds to inhale (the fancy stancy word for this is insufflate: learn something new everyday) crushed tablets of methadone (morphine-like pain medication often used to curb heroin addiction) and for good measure, drinks a few cans of beer. He was found with a sandwich in his mouth a couple of days later when people got concerned that he hadn't shown up for work in a while.

45-year-old woman lies down for the night after taking some morphine tablets, a sprinkling of Xanax (sleeping pills) and a handful of antidepressants and washes it all down with some whisky.

32-year-old with sleep apnea (person who is obese and occasionally stops breathing at night while sleeping) snorts some methadone, takes a couple of Lortabs (morphine-like pain medication) at 8 pm, is found to be barely breathing with a weak pulse and unarousable by boyfriend at midnight, who proceeds to prop his girlfriend up on the bed, places a cold towel on her forehead, and then videotapes her snoring after which he promptly goes to sleep to wake up next to a cold body the next day. He videotapes her so he can prove he did something before she died?!

40-year-old man is home alone for the week because his wife is on a business trip, lays down on his recliner, drinks a couple of beers, takes a handful of methadone and some sleeping pills and goes to sleep permanently while watching the Golf Channel (frankly, I could have told him that you can fall asleep while watching the Golf Channel without sleep aids). His wife finds him on her return home. She had no notion that her husband used any drugs.

35-year-old father of three had gone into his son's medicine cabinet and took all of the Xanax pills the son had been prescribed the day before, had two days earlier, snorted some cocaine with his other son, is found stone cold in the morning by his wife. Their third son had died of an O.D. a year prior. A family that shares drugs together, stays together.

And my all-time favorite: 50-year-old hears some gurgling sounds coming from her roommate's locked door and assumes it was the pigeons outside, goes to bed for the night and had to call 911 in the morning. They found fatal levels of sleeping pills and pain pills in the roommate's system. Apparently, the sleeping pills weren't new for the roommate and she took one too many for the last time. Seriously, gurgling pigeons??

Hindsight is 20/20. I would be willing to bet that if these people had the ability to see back to what they were doing, they all would be saying to themselves: What was I thinking? Unfortunately, none of them could see past their 20 Xanax pills and 20 more methadone pills they were adding to their system on top of the cocaine and booze.

I'll be enrolling these folks for the Darwin Awards next year.

It is past 6 pm on our first day at the M.E.'s office. It is getting dark outside and the place is deserted, most of the staff having left at 5 pm (government workers). It had been fun glimpsing into these last moments of peoples' secret lives.

And then we hear a loud thud from upstairs. Was it a body that had fallen off its gurney?

**Note: The names of the decedents are real and fictional at the same time and the DC numbers are real and made-up as well, so if you're hoping to find a Cycy Sparks with that particular DC #, you'll be out of luck.

Taking the Whoop out of Whooping

My unglamorous secret agent life lands me in the middle of central Mississippi, in the midst of a heat wave, where I had all-you-can-eat fried food and fake Chinese for breakfast, lunch and dinner.
This is a Pertussis outbreak.
I ended up with one week’s worth of indigestion and you-wouldn’t-believe constipation and never heard one single person whoop. Instead, I was, yet again, stuck indoors, in a room with the air-condition permanently stuck at below freezing. I was so miserably cold, I had to go to Walmart and buy myself a dirt cheap rain jacket, which I tried to get the government to pay for, but all I got was a big, hefty laugh.
Our permanent home was a WIC center that gave out food for lower income families with children. It’s amazing the cars you see come by the WIC center for government paid food. I guess one has to have priorities. Nice mid-end SUV or food for the kids? Gee, let me see….
The WIC center is in the middle of a rough neighborhood. We have a trailer park for a neighbor and a run down apartment complex with abandoned cars in the parking lot next to it. So, the windows were covered with paper. I didn’t see the sky for a while.

What comes to mind when you think of an outbreak investigation, especially an infectious disease outbreak? Do you imagine people in white space suits and hoods with oxygen masks attached? Do you imagine large hordes of people quarantined behind negative pressure rooms behind barbed wire? Do you imagine roadblocks, black helicopters?

Well, have no fear, nothing of the sort happened. The first couple of days were spent meeting people. People at the State Health Department, people at the Indian Health Department, people at the district hospital. The outbreak was actually rather well handled; everyone was doing what they were supposed to do: following CDC guidelines.

Pertussis, or whooping cough, is actually a reportable disease. It is also prevented by a regimen of childhood vaccines. Those of us with kids would know and those of us who had to memorize the childhood vaccine schedule for an exam (and then promptly forgot it) would know. And apparently, kids needed to show proof of vaccination before they are even allowed to co-mingle with other kids. I take their word for it since I will not be experiencing the first hand vaccinating of a kid.

So the burning question was this: if the kids were vaccinated and they had to be in order to go to school, then why was there an outbreak? And since the outbreak started on the Choctaw reservation, what was happening there?

There is actually something called “endemic pertussis”. No matter how much public awareness is raised and education is put forth, there will be the few sprinkling of parents who do not conform to recommendations. The ones who home school their kids bypass the mandatory vaccination requirement altogether. The vaccine itself is not 100% protective, which is a public relations nightmare. This is a known fact that the CDC does not readily announce. Therefore, pertussis exists in very low numbers in the community. So the next question that is begging to be asked is: what constitutes an outbreak? This is where the brainiacs at the CDC come in, when they send their Epidemic INTELLIGENCE officers into the field to determine.

Note the emphasis on INTELLIGENCE because there is very little of it. Skinny man is exuding confidence, or trying to, since this is his very first outbreak investigation that he is leading: a grand accomplishment after having been in the EIS program now for two whole months. So when he first meets me, he is giving off the air that his shit smells better than mine and I should not even bother to speak or voice my opinions because I am a mere medical student and I must not be too intelligent. All this in the guise of Chinese politeness, which makes me want to puke and have nothing to do with this person.

Somehow I am eerily reminded of a piece I did earlier this year, when I was in London, on the Cardiothoracic surgeon, Mr Pompous Prick…..(January 12, 2007 How Many Roads Lead to Rome?)

Skinny man kept concluding every sentence he ever said with: “Do you understand?” which, I don’t know about anyone else but it annoyed the heck out of me. Yes, I understand how disease spreads and yes, I understand what whopping cough is and yes, I understand the players involved and why we are here, thank you very much. I am sure I would ask if I did not understand.

And because he was so disorganized and couldn’t multi-task like the female species, I essentially became his secretary, whether I liked it or not. His phone rings and he hands it to me. I had to call the hotel to ask when he can drop off his dry cleaning. I took notes for him while he made his “important” CDC presentation on the emerging outbreak of Pertussis in Neshoba County. Nobody clearly knew my function in the team. I didn’t clearly know my function in the team. And what about learning the art and science of field epidemiology? We won’t even go there.

On Friday of my first week, we made it to the State Health Department in Jackson so Skinny man can give his all-important talk. In the car, prior to our departure, Skinny man looks back to me, sitting in the back seat and says:
“Put on your seat belt.”
Put on my seat belt?
What am I, like three?
I guess I must have not been too concerned at hiding my consternation for he immediately says:
“I don’t mean to sound paternal.”
“But you are,” I say without letting him finish his “but” hanging at the tip of his tongue.
“It’s just that I’ve had only three hours of sleep last night and it is not safe without the seat belt.”
“Oh, so,” I reply “which makes more sense: to have me drive when I’ve had 8 hours of sleep or to have you drive because you want to follow some government protocol and be paternal? I guess doing things by the book doesn’t always make sense, does it?”

I then had the great pleasure of riding back with this person, whom I want to smack upside down the head. Sure seems like one really has to be a pompous prick to make it big in this scientific/medical/research world. Children who have never left school do not realize the life experience that enrich and can only be gotten by actually working in the real world and they turn out to be dysfunctional people who assume other people can, in no way, be more intelligent and would want to be graced by the bounty of their knowledge. Even if he was trying to deliver a public health message to me that wearing a seat belt improves chances of survival, he had completely put me off so much so that I would not want to wear my seat belt to prove him wrong. This is the future of your public health leaders. We might just as well go shoot ourselves because we are all stupid anyway.

So I suffer through this 1 ½ hour journey back, biting my tongue till it bled, trying to give this person the benefit of the doubt. All the while, I am thinking in my head: I have to spend the entire next week with this man? Like the good person I am, I graciously make small talk. We eventually talk about the Choctaw Indians and their casino. The State Health Officer (like the Surgeon General but at the State level) had brought up the issue of funding of pertussis vaccines. Administering the vaccine, though not 100% effective, is one of the ways of nipping this outbreak. The Native Indians had approached the CDC for funds in one of our early meetings with them. They had used up their entire stock of vaccines when this outbreak began and had to borrow from the state. Now, the state-loaned vaccines are running low and this is the end of the fiscal year where budgets are tight. So I brought up the fact of the casinos. I know that in Arizona, the casinos on Indian land are more than profitable. When they first started out about 10 years ago, while I was still in college, they were just humongous white tents in the middle of the desert with slot machines. Today they are lush resorts with golf courses and spas. We have a neighbor who is Navajo and he told us that the wealth, however, is not equally distributed. Although he is not an authority on all casinos run on Indian reservations, I take his word for it. Skinny man and I have a conversation about the profitability of casinos.
“Casinos are profitable by nature.”
“Not every business that appears to be doing well on the outside are doing well,” Skinny man says and gives me this side long glance that I can only describe as condescending, as if to say: Don’t you know that? He then proceeds to give me an analogy of his uncle’s restaurant business.
Restaurant, casino. Like comparing Monkeys and space aliens.
“Which casino do you know of in Vegas that has gone out of business?”
“Casinos go out of business all the time.” Side long glance.
Are you kidding me? Does he know what he is talking about? Winning at the casino is like winning the lottery or playing the odds of winning the lottery, which is never in the favor of the small rollers that play the slot machines or at the tables. If casinos routinely go out of business because people win easily, won’t we all be billionaires by now? People generally loose money! I don’t know about odds, but that’s what my common sense tells me.

And somehow, we start talking about health care and its accessibility, which I don’t recommend doing especially with someone who you already don’t have very much esteem for. This is what he says when the conversation steers us towards Native Indians and African Americans.
“We owe it to them to help them.”
I said: “We have to be real careful with that grain of thought lest we encourage people to be dependent.”
“It’s hard to make an assessment when you don’t really know the situation,” he says to me, side long glance and all. “I’ve been a social worker and people need help.”

I think I about turned a shade of purple.

He then begins a lecture series on the statistical model of standard deviations and means, how people generally fall within the mean. So, if you are poor and all you see around you are drugs and alcohol, then, you will follow the mean, to which I reply:
“You mean to tell me that a decision someone makes doesn’t matter, that he can try his best to chose not to indulge in drugs and alcohol but it doesn’t matter because he defaults to his mean. I refuse to believe that we are just numbers!”

And then the dreaded topic of Universal Coverage is brought up. I am, at this point, itching for a fight and controversy is coursing through my veins. I tell him my opinion about universal coverage, citing the example of Singapore who has had socialized medicine, adopted from the British, and now finds it more profitable and cost saving to turn towards the American model of semi-privatization. I thought it would be interesting to find out why. If socialized medicine worked so well, then why are countries like the UK and Canada in trouble and why is Singapore revamping its health care system? Skinny man didn’t like that answer. With a side long glance, he says:
“Why would you think that would interest me? I can’t believe you don’t believe in universal coverage.” His eyes were saying: what sort of doctor are you?

At this point, I wanted to leave. I thought: what a bad mistake to even want to come. How wrong of me to put CDC up on a pedestal, as if it was the greatest thing in the world when it self selects for pompous know-it-alls, filled to the brim with impracticalities, who have never worked a day in the real health system, to be the health leaders of tomorrow. Do I want to be part of this crowd?

Several days later, after I had brought up the issue of the casinos and their money, we find out that the Pearl River Resort makes something like 20 million dollars a year. Six million of it is devoted to the health care system on the reservation. We were told that the Mississippi Band of Choctaw just elected a new chief. This new chief wanted to challenge the state and the US government to see if they would fund the vaccines. So, do we still owe it to the Indians to help them or do we celebrate the fact that they are able to help themselves and be totally free of government charity to the point of having the liberty to challenge the system?

And then I find out that Skinny man is Hakka, which is the ethnic group my dad belongs to. This makes me want to imbibe large amounts of alcohol and deny my Chinese heritage.
Link News Centers for Disease Control and Prevention Choctaw

Agent 69 - Top Secret Dodo

I was all resigned to the fact that I had to work at Trader Joe's while waiting for Residency to start when I get an email from the infectious disease people at the CDC. I had been accepted to do an Epidimeology elective in Atlanta.

Epiwhatology? Most people in my school can't even pronounce it. I never really got epidimeology. In med school, we had such crappy epi professors that all we did was memorize formulas without actually knowing what they all meant. Attack rates, and, what one epi professor called, The 'Barkers', ARR, CAR, and ORR. I have no clue what they all stand for expcept for a vague idea that they are some sort of calculated risk. So what the hell was I doing applying to an elective in something I only had a vague understanding of that is limited to calculating the sensitivity and specitivity of things? Well, I came across a book in New York while in Colombus Circle, browsing betweeen the shelves of the Borders bookstore, by the name of "The Medical Detectives", written by an author named Berton Roueche. Roueche had worked for The New Yorker and wrote a column detailing the work of epidimeologists who investigated outbreaks. This book is a compilation of his stories.

He started out with a story, set after WWI, about an 88-year old man, who collapses in the street and is sent to the local ER. At the ER, he is noted by the physician to be blue. That is, the color blue. Not more than an hour later, another man comes into the hospital and is also noted to be of the same hue. All in all, the physician saw 12 blue men that night. An investigation was launched and the authorities called in, trying to piece together the common denominator that linked these 12 blue men. It was determined that these men all shared their mornings in a warehouse that served breakfast. In this breakfast hall, there were 15-20 benches, each with the capacity of seating about 12 men. However, these 12 men didn't share breakfast at the same table. What they shared was the breakfast. Each had a bowl of oatmeal. So the oatmeal was analyzed. Inevstigators observed how it was prepared. They even tested the industrial sized pot it was made in and found nothing amiss. Then one of the investigators decided to be present while breakfast was served and noticed a trickling of a dozen or more men into the warehouse. Of all who ordered the oatmeal, he noticed that the majority had added salt to their oatmeal. There was 1 salt shaker for every bench. Now the investigator was curious. He wanted to know where the salt was kept. He went into the kitchen and asked the cook who showed him a large bottle of salt she kept above the stove. On top of the salt that was added to the pot of oatmeal, the men were adding more with their salt shakers at the benches. The investigator found nothing unusual with the bottle of salt the cook had above the stove. Then he asked the cook where the main salt bin was stored that these bottles were being refilled from. And in the back storage room, he found sacks of salt. All the sacks had a preservative in it, a nitrate derivative. This nitrate derivative was mandated by the government to preserve salt during the war and some of it was still circulating in the population in the post war era. Nitrates given in large enough quantities to rats causes methhemoglobin. Essentially, it deforms the red blood cell and red blood cells carry the life giving element, oxygen. So when the RBC becomes deformed, it has diminished its capacity to carry oxygen and under duress, these men turned blue! Only these 12 men were affected because they were the only ones who had added more salt on top of the salt already added by the cook.

I was hooked from then on. Using science and logical deduction, crimes of this nature were solved. I couldn't wait to participate in something like that!

This is the caveat that most authors like Roueche forget to mention: nothing written about stuff is always as accurate as what it is. Somehow, people fail to mention the unglamorous sides to things.

Fast foward till today. I am pretty excited. After a grueling month in a neurology rotation during which I pretended to know what I was doing, I fly the red-eye into Atlanta and suffer through screaming children and overweight people with body smells. I rent a car and make it to my final destination after having 0-3 hours of sleep.

I am at the CDC.

Imagine that.

I sign in (which is the begining of my nightmare) and am greeted by my supervisor who takes me up to the office. I get introduced to my cubicle, which has my name on it (rock on!) and she proceeds to tell me this:

"Welcome to the branch of Respiratory Health and Indoor Pollution. We are the Asthma people."
She is whispering and barely audible.
I feel like a secret agent on an undercover sting.
"I am sure you have heard about the Katrina victims and the FEMA trailer incident that has been all over the news lately."
I nodd my head, even though I had no inkling of what she was refering to.
"Well recently, there have been complaints among the residents who are still living in FEMA trailers and we have been mandated by congress to get to the bottom of these health complaints."
Uh-huh. I nodd again, feeling more espionagy then I ever have in all my 33 years of existence.
"This matter is political in nature. In fact the other day, we were on a field trip to Louisiana and the White House Representative was there and he was on his Black Berry, aparently on the phone with the President, and he said: the President wants an answer in three months."
Gulp. The President?
Then she proceeds to say: "Do you have friends?"
I said I have few, feeling this was the best answer amidst the circumstance.
"Well, it would be good if you just remained very general when you talk to or email them about Katrina FEMA trailers. We don't want to have to subpoena you and all your electronic communications when there is a congressional hearing on this matter." She smiles with a-matter-of-fact look on her face.
Double gulp gulp. Congressional hearing?
"Ok, that having said, we can get down to work."
But we all know better. It's wanting me to keep quiet about something and then telling me I can't tell anyone that prompts me to do the total opposite.

I was half expecting getting all suited up like Bond, with a cell phone that doubles up as a satellite receiver, a shoe that has a hidden camera, a BMW that talks and has a digitalis remedy in the glove compartment. I'm part of the CDC now, Secret Agent, sworn to absolute secrecy.

However, before that, I had to clear security. Since the Secret Agent was not a citizen, I was treated to 10 layers of government scrutiny before I was even allowed on the premises. Since no one knew I wasn't a citizen, by some glitch in the communication process, and the guy that processes the paperwork was not familiar with processing paperwork of individuals who weren't citizens, my approval to enter Government buildings, where sensitive data (on Asthma surveillance) were stored, was pending. I spent one week living in the terror of being sent home for the crime of being a Resident Alien instead of a citizen. When they finally got their heads out of their asses, I was supposed to be entered into the mainframe, except that the person who usually does it is on vacation and the person hired to replace this person was a government contractor with no higher up security clearance. Someone else had to do it, someone that has yet to be identified, whose job was not to enter people into databases. By the time they had it sorted out, another 1/2 week had lasped and I was rearing to go. There you have it for government efficiency. Your government hard at work.

Secret Agent needed to feel purposeful.

When I finally get to Secret Agent status with full security clearance, I spend the better part of two weeks researching literature articles on everything and anything there is to do with formaldehyde and the mobile home, which isn't very much. I spent the better part of my waking hours in a tiny cubicle with no natural sunlight, freezing my ass off because some woman in menopause is in control of the temperature. So when the opportunity came up to do an outbreak investigation in Mississippi and I was asked if I wanted to, I said: "are you kidding me?" At that point I was willing to go anywhere just to be able to see the sun for a couple of days.

And so I went, to Philadelphia, MS, where in 1964, three civil rights activists were murdered by the KKK and their bodies dumped into the Mississippi (remember Mississippi Burning?) river. Just the place for a Pertussis outbreak, right? Right.
My dream of finding the cause for 12 men to be blue is finally becoming a reality.
The outbreak happened on an Indian reservation and has since spread to the neighboring counties. People are getting wary and are casting sidelong glances at the native indian populations, as if they had set a plague on the community. The CDC is called in because the local news media of sleepy hollow have finally found some ants in their pants and are starting to report mostly erroneous facts. The state needed a federal body to cover their ass to make sure everything is running accordingly.

The lead field investigator is a young, skinny asian who had just recently sat for his boards in Internal Medicine. He looked to me like someone who had invested a lifetime in cultivating his gray matter and somehow forgot he had a body, much like a Conehead with a big head and a small body. In fact, he did have a big head, metophorically and literally. He is a newly inaugurated EIS (Epidemic INTELLIGENCE Service) officer, commisoned in the Uniformed Services of America. These are civilian doctors and PhDs who like to dress up and order people around so they can justify their over compensated benefits packages. Of course, there is an upside to being called "Sir" or "M'am" and have someone salute you, unless you consider someone like me, who joined the Navy Reserves secondary to purely mercenary intentions.

There were four of us in the investigation team; a french Belgian, a redneck PhD from Pennsylvania, skinny man, and me. There was a senior EIS investigator who traveled with us for about 3 days. We arrived on the reservation in two groups. I was picked up by the Belgian and the senior EIS officer and we took the 1 1/2 hour trip from Jackson to Philadelphia. This town was apparently named after Philadelphia, PA. However, unlike Philadelphia, PA, this imitation was in the middle of sleepy hollow. It was sleepy hollow central, with not much else in between except dense Mississippi forrests with miles and miles of trees. I can't help but think of the picture I had seen when I visited the MLK Historical Society of a lynched black man hanging from a tree with a sign dangling off his great toe that said: "Sleeping. Do not disturb", surrounded by smiling white men posing for the picture. It is unsettling to visit a place that is so haunted, with trees that know too much.

So when we came upon the gargantuan silver ball in the sky, it was a juxtaposition I could not wrap my mind around. On this tiny highway, the very same one on which the three civil rights workers made their last travels on earth, there stood Las Vegas, glittering and neoned-up, like a harlot but in the middle of the Bible Belt. This was the invention of the 20th century, a native indian creation that sidesteps centuries of ill treatment, to level the playing field. This was the reservation's own Pearl River Resort Casino and Spa.

We checked in. I proudly displayed my "government" issued, hot of the press, Department of Health, ID and got ushered into my fantastically dim room, air-freshened with the scent of the day: stale cigarette smoke de jour, with the sound of a thousand slot machines muted in the distance to lull me to sleep. I lower the temperature to a chilly 61 degrees. Smells are not so apparent in this temperature range. While I chilled in my room, watching CNN, someone knocks on my door. At the door were two ladies from room service.

"I didn't order any room service," I said.
"It's ok. This plate of fruit has been paid for and it's yours."
"But I'm not who it says on this card. I'm part of his party but he isn't even checked in yet."
"Really, it's yours, enjoy it."
Ok, I said to myself. Must be some nice Secret Agent welcoming gift from the Reservation thanking the CDC for coming to the rescue. I let the ladies in and started to unwrap the fruit. Pineapple, honeydew, canteloup and grapes. I was hungry! There was also this fantastic to-die-for strawberry mousse.

At this time, the Belgian calls and I ask if she had a fruit platter brought up to her room. She said she had to switch rooms and that maybe, the platter was brought up to the room she'd just vacated and hadn't gotten to her yet.
"Well," I said "there's more than plenty for me and you are welcome to share some of it with me."
"Maybe after dinner," she says in her inspector Clouseau accent.

We finally meet up with the rest of the party. Skniny man and redneck PhD came in a separate vehicle. I am partially satiated with the fruit platter as we walk to dinner, an all-you-can-eat-buffet, Vegas style but with southern food (everything deep fried to death).

I ask everyone whether or not each had received a fruit platter. To my dismay, I was the only one. Hmmm. Mighty strange. At this time, skinny man gets a call from his fiance who asks him how he liked his fruit platter. And flowers.

Oh-oh. Why does this not sound good?

Needless to say, I was the butt of many fruit jokes to come. Apparently, since skinny man had reserved all four rooms, the hotel had automatically assumed he had checked-in and then promptly assigned me the wrong room. Either that or they had assumed skinny man and I were related, which grosses me out just to think about it.

For the most part, the first night passed uneventfully.
I stopped eating fruit that belonged to my boss.