“Give me your E. coli, your polio, your huddled Tuberculosis yearning to kill free.”
Statue of Liberty, 2025
Originally I was not going to write a post this month. As this goes live, I am in Adelaide on a trip down under. When I was young, aka in my 50s, I would try and write a blog entry while traveling. It is amazing how concentration and stamina fade in the 60s. My age, not the decade. I figured, given other commitments and encroaching decrepitude, that I would not have the wherewithal to churn one of these out.
Then my feeds noted there was an E. coli outbreak in 15 states that killed one and sickened at least 88. The CDC told no one. Holy Bad Word. So what follows is a quick one (while I am away).
As regular readers know, I was an infectious disease doctor for 36 years if you include my fellowship. For most of my career, I was the only ID doc for 3 or 4 hospitals, where I saw all the consults and was in charge of infection control for 2 hospital systems and, for a year, and LTAC.
Just me. All by my lonesome. The buck stopped with me. And you cannot practice medicine alone.
For years our Saturday night tradition is to watch Noir Alley on TCM. Most of the movies are from the late 1940s and 50s. I am always amused when a doctor is needed in these old movies, be it for a gun-shot wound or to deliver a baby. Do they go to the hospital or ER? Nope. Someone goes to the doctor’s house, usually late at night, where he is awakened, along with his long-suffering but understanding wife in curlers. After a brief push back at the late hour, he grabs his black bag and, kissing his wife, he is off to attend to whatever medical problem the script has thrown his way. And he always takes care of the problem.
Although I have a Zaphod Beebleox level of self-regard, there were many situations in my practice that occurred where I needed advice. I had my boss, who was one of the best clinicians I have ever known. And there were other ID docs in town who I could talk to at conference. But they all had the same problem I did. They lived and practiced in Portland.
Portland, and the Pacific NW is the best part of the US, if not the world. That is an absolute truth. Except for infectious diseases. You are not going to see a lot of tropical illnesses nor have experience with outbreaks of odd organisms. So who do you call?
The county and state public health departments and the CDC. I could always rely on them for the experience and expertise I lacked. For 30 plus years, they had my back and helped with the odd and unusual cases that are part of ID.
Experts that were only found only in the government played an important role in allowing me to provide the best care I could for complex and unusual cases. Now with the CDC being gutted and local public health always underfunded, I thought I would take a stroll (with a walker) down memory lane and reminisce about the role of government in helping a lowly ID doc practicing just to the left of the middle of nowhere.
Even though the song says, you don’t know what you’ve got till it’s gone, I always valued the giverment. Could not have done it without them.
County Health
Tuberculosis. Just common enough, I would see a case or two a year. Uncommon and variable in presentation where you can develop an extensive experience. Tb is almost always in patients with little to no support, financial or social. Combine that with its interactivity, potentially toxic medications, unpredictable antibiotic susceptibilities and an often horrible death (two of my Tb deaths were due to ruptured Rasmussen aneurysm, they drowned in their own blood, the rest died of refractory miliary disease), it is nice to have experienced help. Measles is bad enough. We don’t want a return of TB.
Tuberculosis, also known as “consumption”, “phthisis”, or the “white plague”, was the cause of more deaths in industrialized countries than any other disease during the 19th and early 20th centuries. By the late 19th century, 70 to 90% of the urban populations of Europe and North America were infected with the TB bacillus, and about 80% of those individuals who developed active tuberculosis died of it.
I called county health with every active case. Not only to reassure me that I was indeed doing right by the patient, they provided medications and, most importantly, made sure the patient was kept in proper isolation and took their medications properly. County health is involved with treating and controlling many other infections, such as syphilis and AIDS, but for my practice their help in TB was invaluable.
TB care has been gutted thanks to foreign aid cutbacks and people are dying as a result. Infections do not give a rat\u2019s ass about borders and Tb anywhere is a plane trip away from Tb in your city. Tb antibiotic resistance is a nightmare, and cutbacks are helping to ensure we will be seeing more Tb.
State Health
Rabies. People get bit by the damnedest things: not just dogs and cats, but squirrels, raccoons, opossums, and damn near anything that has teeth. And bats end up in the damnedest places. I was watching a Jack the Ripper movie one summer and right at the most tense part of the movie a bat flew into the living room. I shrieked. I have had bats in the house several times over the years. Always scares the hell out of me. What do you do with a bat exposure? What do you do with the patient done gets bit? Call the State. They know which animals are a rabies worry and who needs rabies prophylaxis.
It is critical to have an organization, like State Public Health, who tracks unusual infections. I estimated that there are around 1500 pathogens I needed to know. You can’t test for all of them. Well, given the newer diagnostic technologies, that may no longer be the case. And pathogens move around, either from human intervention or due to climate change. As a clinician it is invaluable to know what pathogens are where. Otherwise, how would you know that Cryptococcus in invading the great Pacific NW? Of that West Nile, Hanta and Lyme are very rare? Not now, anyway. State Public Health departments are invaluable.
And the State was someone to call when something odd would occur. If I saw a small cluster, say two or three cases, of invasive Group A Streptococcus or infections after a tattoo. Trust me, you don’t want a tattoo infection. I had someone to call to investigate. An ounce of prevention and all that
CDC
I live in Portland, Oregon. The best Portland. Again, another fact, not opinion. Not much in the way of parasites in this part of the world. Almost every worm I have been asked to identify has been an earthworm. But people do travel and can bring home some unusual diseases. Like Malaria. It’s a difficult pathogen that kills over 600,000 people a year worldwide, but the US sees 1500 cases a year. Hard to gain a lot of clinical experience in Portland. Antibiotic resistance is common and increasing in the various malaria species around the world. Thank Febris for the CDC. Experts are available 24/7 to help with diagnosis and appropriate therapy. The last thing you want as a clinician is a patient dying because of a lack of experience. With the CDC at your back, that was never the case.
Other rare parasites I saw over the years that the CDC was incredibly helpful were Leshmania and Trypanosoma. The only place for proper diagnosis and access to medications is the CDC. You might think, I don’t need to worry. These are a few of the many infections coming north with climate change that no wall will ever stop. As an example
The southern half of the United States contains enzootic cycles of T. cruzi, involving 11 recognized triatomine vector species. The greatest vector diversity and density occur in the western United States, where woodrats are the most common reservoir; other rodents, raccoons, skunks, and coyotes are also infected with T. cruzi. In the eastern United States, the prevalence of T. cruzi is highest in raccoons, opossums, armadillos, and skunks.
Brucella: an important disease of swine and of economic importance. Pig farms, and other animals, need to be Brucella free. So imagine you have a patient who buys a local pig for a pig roast, slaughters it, becomes ill and is diagnosed with Brucella? All sorts of potential ramifications for the pig farms and feral pigs. The CDC was involved and, long story short, it was genetically identical to the stains in Tonga, where he had been borne It was reactivation Brucella, not a new infection.
Brucella suis infection was diagnosed in a man from Tonga, Polynesia, who had butchered swine in Oregon, USA. Although the US commercial swine herd is designated brucellosis-free, exposure history suggested infection from commercial pigs. We used whole-genome sequencing to determine that the man was infected in Tonga, averting a field investigation.
Outbreaks: Legionella, Flu, HIV, Food-borne illnesses, West Nile Hanta, Mpox, Nagleria, Avian Flu, and on and on. The CDC and the MMWR are invaluable for information on what infections are happening where and why. As a clinician, you rely on the CDC is a resource of epidemiological data without which you could not practice ID. I mean, how else would I know that castrating sheep with your teeth was a risk for Campylobacter?
During June, both patients had participated in a multiday event to castrate and dock tails of 1,600 lambs. Both men reported having used their teeth to castrate some of the lambs. Among the 12 persons who participated in the event, the patients are the only two known to have used their teeth to castrate lambs. During the multiday event, a few lambs reportedly had a mild diarrheal illness.
As a result and because of the County, State and National Public Health departments, docs practicing anywhere in the world with a computer can have state-of-the-art access to the best information on the diagnosis and treatment of infections.
The government, combined with PubMed, truly transformed how I practiced ID because it gave me knowledge and access to expertise that would otherwise have been unavailable.
I cannot imagine providing care to the odd cases that came my way without their help. But that looks to be a real possibility going forward. Invaluable knowledge and expertise is being shed at the CDC and Co., like a cybertruck panal.
People do the damnedest things and acquire infections as a result. Not that we are going necessarily find out moving forward. For example, they are stopping testing for infections in raw milk, a most excellent way to transmit a variety of infections. They are going to stop looking for Salmonella in chicken.
Don’t ask, don’t tell is not the best approach to infectious diseases. Come September, when vaccines will be found to cause autism (and you know that’s coming), combined with a lack of infection epidemiology and prevention, I will have retired too soon to see some great pathology. I always said that ID was like birding, only interesting, in that you could have a life list of diseases. Some, like measles, smallpox and plague, you did not want to see. But the opportunity to see so many preventable infections. Ah. Love me my infectious diseases.
From an ID perspective, we are heading for wide open borders, no walls, no border patrol, providing both an all-you-can-eat and a get-out-of-jail-free card to the most prolific of killers of history, and letting them party likes it’s 1799.
I was dreamin’ when I wrote this
Forgive me if it goes astray
But when I woke up this mornin’
Could’ve sworn it was judgment day
The sky was all purple
There were people runnin’ everywhere
Tryin’ to run from the infections
You know Kennedy didn’t even care
Say say
Two-thousand-twenty-five party over
Oops out of time
So tonight germs gonna party like it’s 1799
(I was dreaming’ when I wrote this)
(So sue me if I go too fast)
(Life is just a party, and parties weren’t meant to last)
Infections all around us, my mind says prepare to fight
So if I gotta die I’m gonna listen to my body tonight
Yeah