Biologist Reinforces POGO’s Letter Concerning CDC Investigations
August 12, 2005
The letter below was written by Dr. Patrik Bavoil, the Director of the University of Maryland-Baltimore’s Infectious Disease & Immunology Track (background on Dr. Bavoil: http://bms.dental.umaryland.edu/faculty.asp?ID=7). Using three examples of flawed CDC investigations—investigations of the 1984 Rajneesh cult bioterrorism case, the 2000 West Nile virus outbreak, and the 2003 laboratory infection of a USDA researcher (the investigation occurred in 2004)—Bavoil argues that the CDC’s investigations suffer from poor training which leads them to sometimes jump to incorrect conclusions with implications for public health and safety. It is a follow-up to a POGO July 2005 letter to several Congressional committees.
Patrik Bavoil, PhD
The Honorable Joe Barton, Chairman
The Honorable John D. Dingell, Ranking Member
The Honorable Nathan Deal, Chairman, Subcommittee on Health
The Honorable Ed Whitfield, Chairman, Subcommittee on Oversight and Investigations
Dear Representatives Barton, Dingell, Deal and Whitfield:
I write this letter as a concerned citizen and in reference to the letter dated
The investigation of Dr. Hsia’s laboratory-acquired infection has confirmed the expertise of CDC epidemiologists in tracing infectious agents from the point of contamination to the infected victim using sophisticated molecular methodologies. Paradoxically, this investigation has also revealed their comparative incompetence at investigating people, particularly people who have an incentive to cover their role in a contamination. In the case of Dr. Hsia, the investigators unequivocally traced E. coli O157:H7 recovered from the victim to the experiment using a DNA-based method called pulse-field gel electrophoresis. However, they were ultimately unable to identify the individuals who designed, performed and supervised the experiment and therefore caused the contamination. Instead, the CDC report from the investigation placed the blame on Dr. Hsia who, based on the scientific record, had not worked on E. coli O157:H7. While she laid in a coma, Dr. Hsia was blamed for supervising the faulty experiment and the technician performing it by the technician himself and his formal supervisor, who by doing so escaped further investigation. The administrative record however indicated that Dr. Hsia had no supervisory role. Soon after she woke up, Dr. Hsia testified that she was neither involved in the project nor responsible for the technician, yet her testimony was entirely ignored by the CDC investigators. Because of these investigative shortcomings, the true cause of the initial contamination was not identified and as a result at least two other individuals may have been infected later.
There exists a startling parallel between this flawed investigation in 2004 and a previous case also involving a CDC investigative team. In 1984, several hundred people were infected with Salmonella enterica serovar Typhimurium in a rural community in
An egregious parallel in the failures of EIS investigators to even get close to the cause of the contamination in 1984 and 2004 is their striking inability/unwillingness to weigh in circumstantial evidence. Science, by its very nature, tends to regard circumstantial evidence, even overwhelming, as suspect. In contrast, circumstantial evidence is critical to police investigations and may be used in court proceedings. For instance, there were strong indicators that the
Although the scale of the outbreaks in
Investigative “tunnel vision” by CDC was also a feature of the investigation of the
A troubling corollary of the above comes from transposing these investigative failures to an actual small scale bioterrorist attack, for example a “test” attack or “dry run” by a terrorist cell. In such a scenario, the local State Dept of Health would receive the first call as most such attack would first be indistinguishable from a natural outbreak. State Health may then select to call in the CDC and the CDC may send EIS officers to investigate, if the outbreak is judged severe enough. Based on the investigation of Dr. Hsia’s accident, EIS epidemiologists would likely trace the culprit agent to its source. Unfortunately, they would also likely be ineffective at recognizing the roles played by individuals in the outbreak and would not recognize distortions of facts. It is likely that a small scale bioterrorist attack would be as likely to escape early detection today as the Rajneesh bioterrorist attack did in 1984. The recent, much publicized anthrax attack of 2001 was readily recognizable as an act of bioterrorism because it was targeted to well-known individuals. However, it was relatively small in scale and a valid question to ask is whether it would have been detected as an attack, had it not been targeted.
Current training in epidemiology of the CDC EIS officers is glaringly insufficient to investigate cases involving individuals who may lie to hide negligence or criminal intent. EIS officers should be trained in police work, particularly at recognizing and valuing circumstantial evidence that, in the absence of reliable testimony, may be the only evidence available to link a contamination to someone’s ill intent. Alternatively, an oversight commission should be created to ascertain that EIS investigators have not overlooked human distortions of epidemiologic findings and responsibilities. Indeed if EIS officers are unable to recognize fallacious testimony about an accidental contamination caused by someone’s negligence, how can one expect them to recognize lies a bioterrorist would make about a biological attack? An essential element of an efficacious response to a bioterror attack will be our ability to quickly and decisively distinguish such an event from a natural outbreak. I have little confidence that this would happen in view of the recent failed investigation of Dr. Hsia’s lab-acquired infection and the history of similar “tunnel vision” by CDC EIS officers.
I will be grateful for your renewed attention to this problem.
Patrik Bavoil, PhD
PS: In the event I cannot be reached, please contact POGO investigator Nick Schwellenbach at (202) 347 1122.
CC: Senate Committee on Health, Education, Labor and Pensions
The Honorable Mike Enzi, Chairman
The Honorable Edward Kennedy, Ranking Member
The Honorable Richard Burr, Chairman, Subcommittee on Bioterrorism and Public Health Preparedness
House Committee on Homeland Security
The Honorable Christopher Cox, Chairman
The Honorable Bennie Thompson, Ranking Member
The Honorable John Linder, Chairman, Subcommittee on Prevention of Nuclear and Biological Attack
Senate Committee on Homeland Security and Governmental Affairs
The Honorable Susan Collins, Chair
The Honorable Joe Lieberman, Ranking Member
The Honorable Norm Coleman, Chair, Permanent Subcommittee on Investigations