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Backstories in Epidemiology

Novick, Lloyd F., MD, MPH

Journal of Public Health Management and Practice: September/October 2018 - Volume 24 - Issue 5 - p 411–412
doi: 10.1097/PHH.0000000000000855

Brody School of Medicine, Greenville, North Carolina.

Correspondence: Lloyd F. Novick, MD, MPH, Editor-in-Chief, Journal Public Health Management and Practice, Brody School of Medicine, Hardy Bldg, Greenville, NC 27834 (

The authors declare no conflicts of interest.

This September-October issue of the Journal of Public Health Management and Practice (JPHMP) includes an article titled “Mystery in the Pines.” It recounts a large typhoid epidemic in the Catskill Mountains Borscht Belt written by editorial board member and former New York State health official, Gus Birkhead. This article is the first in a collection of historic narratives called “Backstories in Epidemiology.” Compiled and edited by John Marr, Carole Novick, and JPHMP Editor Lloyd F. Novick, this series is written in the spirit of the classic Eleven Blue Men and Other Narratives of Medical Detection by Berton Roueche (1965, Berkeley Medallion, New York). Roueche was a writer for the New Yorker for nearly 50 years, and his true stories of medical detection originally appeared there in a column called “Annals of Medicine” first published in 1948. A number of Roueche's original 12 stories involved the New York City Health Department and epidemiologist Dr Morris Greenberg. Dr John Marr as Director of the Bureau of Communicable Diseases and myself as Deputy Commissioner of Health of the NYCDOH in the 1970s had the opportunity to work closely with the late Morris Greenberg, making these cases very meaningful to us.

This new collection of cases is in the spirit of Roueche's work. In each of the next several months, a new true medical mystery story will be posted on our companion site JPHMP DIRECT. Following the case format used in JPHMP, actual situations with protagonists identified by name are used. Roueche's stories provided an introduction to epidemiology for many public health professionals. In fact, the Centers for Disease Control and Prevention lists this book as a resource for teachers and students. “Though somewhat dated, this collection of New Yorker articles carried out by New York City health officials during the early-mid 1900s served to introduce many people to public health and epidemiology.”1 It is our intention in developing Backstories in Epidemiology to provide an updated collection. After publishing our first 6 cases on a monthly schedule on JPHMP DIRECT, we will welcome submissions from other epidemiologists who can adhere to our story format and provide new mysteries of medical detection for our readers.

We are publishing these stories not only because of their interest but also because of their importance to practitioners and students of public health and health professions at all levels. With the explosive growth of public health education at high schools and community colleges, we believe there is a broadening audience for this type of content. Following our case format, each case is accompanied by questions for the reader.

Appearing on JPHMP Direct, as supplemental content for the September issue, is a case authored by John Marr and Marcus Horwitz: “The World's Deadliest Poison.” It is an account of botulism in a New York City family resulting in 2 fatalities. In our following issues of JPHMP DIRECT, stories will include “It's All in the Bottle,” an apparent outbreak of tuberculosis in a Virginia state prison for women; “Bad Blood: The Gift of Giving,” a malaria outbreak in New York City; “Appendectomy Masquerade,” an epidemic initially attributed to appendicitis in upstate New York; “The Babies Are Dying,” newborn deaths in a West Virginia rural hospital nursery; “Clam Aches,” an outbreak at a union picnic from Maine Clams; and “Of Bites and Men: The Most Dangerous Urban Animal,” a story where the number of human bites exceeds shark bites.

Two additional investigative medical mystery cases authored by John Marr can be found in JPHMP's 21 Public Health Case Studies in Policy and Administration published in 2017 by Wolters Kluwer.2 They include “It Takes a Village,” describing an outbreak of amebiasis in men living in the West Village in the 1970s presaging the AIDS epidemic, and “Typhoid Moishe,” a typhoid epidemic spread by a Hasidic rabbi officiating at Bris ceremonies (circumcisions). The latter case has a contemporary epilogue with the transmission of herpes simplex virus by rabbis at these events.

Epidemiological approaches have undergone many changes since the publication of Roueche's cases and even the stories we are publishing with this collection. For example, in the “Mystery in the Pines” story, Birkhead mentions the New York State Health Department using cards to keep a registry of known typhoid carriers. Marr also mentions cards in his case about human bites in New York City. Now computerization has greatly facilitated disease reporting and outbreak investigation. In-depth studies using GIS (geographic information system) technology became available in the mid-1990s. This has replaced sticking pins into a map to chart disease occurrence. GIS now can be used to link database information with maps to provide for spatial analysis.

In the “Mystery in the Pines” case, a bacterium was recovered from a typhoid carrier and also from the putative vehicle of infection (orange juice). Currently, but not available at the time, was genetic typing of the isolates of the bacteria from the carrier and the bacterium recovered from the vehicle of infection. However, even now currently used techniques to obtain DNA fingerprints of bacterial agents of infectious diseases frequently cannot discriminate between all bacterial strains of the same outbreak, making it difficult to trace the spread of the disease. A recent solution to this problem is the application of next-generation whole-genome sequencing techniques, which allow all available genetic information of each clinical isolate to be determined. The availability of comparatively cheap whole-genome sequencing technologies in the last few years enables monitoring all changes in a bacterial genome and providing maximum discriminatory power between 2 isolates.3

We hope our readers find Backstories in Epidemiology to be rewarding reading. As editors and chapter authors in this series, we have found this to be an enjoyable and worthwhile endeavor.

The majority of the cases in the Backstories of Epidemiology collection have so far occurred in the 1970s and 1980s, with 2 occurring in the 21st century. While all of these cases do update Roueche's work by an average of more than 30 years, we are seeking additional contemporary cases. We believe this is possible, even realizing some of the current challenges of the format that captures real situations and identifies protagonists (not those individually affected).

If you would like to contribute a backstory from an actual epidemic, please contact the editor for consideration at

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1. Centers for Disease Control and Prevention. Resources for teachers and students. Accessed May 25, 2018.
2. Novick LF, Morrow CB, Novick C, eds. JPHMPs 21 Public Health Cases in Policy and Administration. Philadelphia, PA: Wolters Kluwer; 2018:185–210.
3. Schürch AC, Siezen RJ. Genomic tracing of epidemics and disease outbreaks. Accessed May 25, 2018.
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