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.
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