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An Interview with Dr. Steven Wiersma
Photo editor Robert Stevens died in Florida last fall from anthrax spores sent through the mail, and another person there, Ernesto Blanco, was hospitalized with the disease. Both worked in the American Media Inc. building in Boca Raton. A thousand others in the building were tested and advised to take preventative antibiotics.
Epidemiologist Dr. Steven Wiersma led the state's public health investigation into the anthrax cases. Following is an edited transcript of NPR reporter Richard Knox's interview with Wiersma. He talks about what went right with Florida's response to the attack, and what's needed for a better response to bioterrorism on the local public health level in the future.
• Lessons learned from anthrax
• Communicating with the public
• Lead investigator: health officials or law enforcement
• Shoe-leather epidemiology
• Public health and homeland security
• Problems in the response to anthrax
• Smallpox scares in Florida
• Technology and detecting bioterrorism
Richard Knox: Are we safer than we were a year ago?
Steven Wiersma: I believe we are safer than they were a year ago. First of all, we know a lot more about our response -- strengths and weaknesses and gaps. And I think we've moved to fill a lot of the gaps. We have a much improved response capability today. And certainly it's going to be an ongoing process. I think with each ongoing month our response capability is going to improve.
Knox: What lessons were learned from the anthrax attacks?
Wiersma: We realized the importance of having good communication between clinicians seeing patients and public health. That's always one of the underpinnings of good public health practice. But as the number of clinicians has increased while the public health workforce has decreased, (communication) has gotten worse. I think in Palm Beach fortunately in this particular case … the system worked well.
But we realized we had to strengthen that in other places that it may not be as strong. That's something we're doing very actively.
The second part was in the response. We realized it takes a lot of people to respond to these incidents. And that we need to be able to mobilize field epidemiologists. People that aren't just comfortable sitting behind a computer crunching data, but comfortable being out on the street talking to people, looking for places where exposure may have occurred, organizing vaccine clinics, monitoring for adverse reactions, talking to various employees in different work settings. That was a shortcoming that I think we worked very hard to remedy.
Knox: How many people do you think were ultimately needed to help investigate and contain the incident?
Wiersma: I think the point is not what we ultimately needed but where the people came from. Some of the problem is we had to borrow from the federal government. In this situation, that worked out just fine. We had the first case, and the federal government devoted all their resources to our situation, and that helped us very much.
But we realize that's not always going to be the case. And we need to have a lot of that same kind of workforce we were forced to borrow from CDC, in the form of its Epidemiologic Intelligence Service (EIS) officers. Fortunately, the governor of the state of Florida, Jeb Bush, and the legislature moved very quickly on that request. And even as early as late fall of last year monies were appropriated to start a Florida EIS program. So we're replicating some of these things that we know work but make sure we have that capacity at the state level to respond to potential bioterrorism events, as well as other events.
Knox: How much additional money have you been allotted?
Wiersma: That appropriation started a number of things moving. It funded seven positions. And we were able to immediately start a program to train field epidemiologists similar to the federal EIS program. A program in which we can take them and mobilize them very rapidly to places we need them. We've already used them in hepatitis A outbreaks in central Florida and in investigating an outbreak of antibiotic resistance organisms. So we know it's going to work. The key is to be able to produce them in adequate numbers. We started out with seven positions, of which we put six people in the field. We're planning to double that with some federal dollars.
Knox: The federal government has given Florida $47 million. How much of that is going to the epidemiology bureau?
Wiersma: Total funds for epidemiology and surveillance is $8 million, but that's statewide. A large portion of that is actually moving to the counties. We work very much in concert with our county health departments. There are 67 counties in Florida, and we work very closely with them. Because again, they're the people out there interacting with the physician. They're the ones who know the community the best.
Knox: What have you, personally, learned from the anthrax attacks?
I realized that it's important to talk to our communities and partners in advance. I think one of the unfortunate things is that, as we mobilized and as media coverage unfolded, a lot of citizens were just being made aware of public health for the first time.
Knox: Why is it important that these relationships are set up in advance?
Wiersma: It facilitates the work that we need to do in a crisis setting. Walking in and not knowing your partners or having your partners know you puts you at an extreme disadvantage. And we saw that with law enforcement, for example. They weren't used to working with public health. At the end of the day, they realized we had some very amazing investigative techniques that were very useful to them. At the same time, there were things about law enforcement and the need to preserve a chain of custody and a crime scene that we weren't very aware of. That's just one example, there were many, many others. Working with the school system, the sheriff's office. Working with pharmaceutical industries. You remember there were stockouts. I think we're going to need to be very creative in a crisis situation, especially a situation that's most likely going to make anthrax look very small in the future.
I'm thinking of smallpox. That is a big issue.
Knox: In an early interview, you said that the public health response would be very different if there was more than one case of anthrax. Then a second case did appear in Florida, with Mr. Blanco. (Ernesto Blanco, who worked in the American Media Inc. mailroom was hospitalized for anthrax, but survived.) How did the response change?
Wiersma: I don't think Mr. Blanco changed things dramatically. I think what I was alluding to is that things would have been vastly different if we had a massive outbreak or a massive attack of this disease. And that's something I still think about every day. The one, two, three or 10 cases of something is something we deal with quite frequently in public health. That's not limited to anthrax. We see that in other life-threatening diseases like meningitis every day in Florida. What I am concerned about are things like pandemic influenza or smallpox or anthrax on a much broader scale. I think that's going to really test our ability to respond.
Knox: One thing that seemed to be different, just from an observer's point of view, is after it became obvious that it was indeed a deliberate act, the communication public health agencies had established with the public and the media came to an abrupt end. How did it look from your vantage point?
It's a little difficult to share some of those thoughts, because I still work for the same organization and the same issues are in place. But I think clearly there were issues of national security that became evident and they shifted the focus of our media availability and outreach.
It still puzzles me a little bit that so many people found it a big surprise that this was an intentional act, because going into it we in public health felt very strongly that this was most likely intentional from the very beginning. We did keep things in balance by telling everyone -- and maybe this message was heard too clearly -- that we were keeping an open mind. We were looking at the potential for naturally occurring anthrax. But I think clearly when it crossed that threshold with the second case, we knew that this was intentional. A lot of people started thinking very differently about how information was communicated. And there were some decisions made at a very high level in both state and federal government that influenced the type of contact that we were having with the media.
I think it's very important, no matter what the situation is, that the public be able to get information from whom they believe is a credible source. I believe very strongly that sometimes the public health officials closest to the local level are that credible source. I know Dr. Jean Malecki (Health Officer for Palm Beach County) provided a very familiar face to the residents of Palm Beach County. And many people found her to be that credible source. Some people in the state of Florida were very familiar with hearing me talk about issues of West Nile issues in this state. And I think I could provide that credible source for many people in this state.
So I think as policymakers look at how they want to handle communications they need to keep that in mind. Sure, it has to be balanced with national security needs and the ability to control information.
Knox: At the heart of any bioterrrorist event, is how public health workers and law enforcement members work together, and with that, the inevitable tension that may arise between the two agencies. Did you see that happen?
Wiersma: It definitely has come out. And I think we're already making steps to remedy some of that tension that exists between law enforcement and public health. There needs to be a better understanding of the importance of each party in preventing disease. That's the mission of public health, and catching the perpetrator is a good prevention strategy.
But we very much wanted to move quickly and unimpeded to get the necessary evidence we needed to then start implementing prevention recommendations. And we did that very effectively, but unburdened with a lot of procedures that might be very important to law enforcement -- like tagging things and keeping copious notes and chain of custody issues. We moved in street clothes to all kinds of different restaurants frequented by Bob Stevens, recreational settings, all through his office setting. And only by having that very rapid response were we able to identify the office as the site of exposure to anthrax.
There are advantages and disadvantages of working together. Public health is charged with ensuring the confidentiality of information that we get. And we know from other settings that it's very difficult to work hand in hand with law enforcement. For example, hepatitis A and methamphetamine users in Florida -- a big investigation we've recently been involved in -- we're talking about illegal activities. And people may be very willing to share certain information with public health and not with law enforcement.
So it isn't always practical for us to work together -- maybe just a more clear understanding and even more training in each other's methodologies would be helpful. We use some methods in public health that surprisingly weren't really known by our some of our criminal investigative colleagues, and I think they might be very useful in criminal investigative settings.
Knox: Law enforcement members were surprised by some of your investigative techniques?
Wiersma: They were surprised at some of the results we were getting. But I think maybe some of it goes back to that whole credibility issue. We're seen as nonthreatening members of the community that are there to prevent disease and disability. And sometimes we're very effective in that role of getting information from people -- much more effective than law enforcement might be. We don't have badges and don't have guns. That makes a big difference when you're talking about a life-saving event and a quick response.
Knox: Anthrax spores were eventually found on Bob Stevens' keyboard and in the mailroom of the American Media Inc. building. Your crew narrowed it down to those locations, right?
Wiersma: Yes. That happened because a bunch of our people -- epidemiologists and laboratorians in street clothes -- were sent out looking for something. And we found it. And we also found some very interesting information about suspicious letters received by other AMI employees, including one that was very widely reported in the media that contained a fine powder and a little charm that looked like a Star of David in it. We got that information very quickly and very readily from some of our sources.
Knox: You basically went in, traced Bob Stevens' contacts and established trust?
Wiersma: That's basically it. People are willing to trust us when they know what our objectives are. We were able to go to coworkers of the index case (Bob Stevens) and interview them about suspicious letters, about things they observed him doing. And were able to corroborate a lot of information and gather a lot more new information our law enforcement colleagues might not have had access to.
Knox: One thing that stands out last October, was that after Mr. Blanco's case came to light, a state public health briefing was cancelled, and then the FBI held its first briefing. One of the FBI agents misspoke about anthrax, implying that it was a virus or that it was contagious. And I think I saw you cringe in the background. The reason I bring it up, is that from the other side of the lights, it looked like the public health people were being shoved into the background, just as there were multiplying questions about health risks. Was it frustrating to be big-footed like that?
Wiersma: Yes … and that's not a radio answer by design.
At that point there was a major shift, both in terms of who was going to lead the investigation as well as who was going to provide information to the public. Prior to last year's anthrax even, we all agreed that bioterrorism would be a criminal event and the FBI, you know, our federal law enforcement would have the lead role.
But I think what you saw on the ground was that they deferred very much to public health because public health has the tools both to investigate and to respond quickly to protect the health and well-being of the people that might have been exposed.
So who's going to have the lead role in that situation? It's up to other people besides myself to say what the proper roles are for the future. But I definitely see a trend, I think, in planning and the domination of law enforcement. And I'm not the appropriate one to say whether that's correct or not.
Knox: Not just in that situation, but over time you're seeing a shift toward law enforcement taking the lead role?
Wiersma: Yes.
Knox: I just wonder what the role of public health will be in the new Homeland Security agency, and whether that will institutionalize the shift you're talking about?
Wiersma: I have the same questions.
Knox: Is that something public health offices around the country are worried about?
Wiersma: I think so.
Knox: What questions does that raise?
Wiersma: What happens to public health in a domestic security structure? Is it the same dual purpose with the toolbox that we use currently -- so that it can be as robust to deal with meningitis as with anthrax as with smallpox? Or does a certain segment of it get carved out along with personnel and resources to -- and this is really no slight on people I respect very much -- but the old firehouse mentality, where people sit and wait for an attack.
Right now public health doesn't wait. We use these tools day-in, day-out to respond to needs in our communities. And we also make them available for things like bioterrorism. And I think the thrust in recent funding exercises has been to make sure they're more robust. And to enhance those capacities, not to change them in a dramatic way. But I don't know how this domestic security organization is being rolled out -- it's too new for me to be able to comment.
Knox: Well, I guess one thing we ought to think about as we all move toward greater security is the need to focus more before the next emergency on how to integrate public health security.
Wiersma: Yes, and we also need to be sure that our ability to be flexible with the public health resources we have is increased. I think what we've seen over time is a somewhat diminishing investment in public health. And we realized during anthrax that we can't have a low state of readiness. We need to have people out there that have these skills, because they're very important for bioterrorism, just like they are for other public health threats.
I definitely believe we need to better expose the public health investigative workforce to law enforcement techniques and vice versa. That both parties need to be comfortable working with each other, because there are very, very clear roles for each in the use of bioterrorism. And I think we really have not dealt a lot with our colleagues in law enforcement and they have not dealt a lot with public health in the past and there's a great need for bridging that divide.
Knox: Is cross-training under way?
Wiersma: There is a federal initiative we're involved in to develop a course -- the first of its kind that I've heard of -- that would cross-train people in public health and law enforcement. The working title is forensic epidemiology. I think that's subject to some change. It's basically criminal investigative techniques 101 for public health, and public health epidemiology 101 for law enforcement. It uses three case studies. As currently conceived by the CDC, which is developing it, one of them is the Palm Beach anthrax situation.
Knox: In Florida, you gave people a centralized place to go get nasal swabs and prophylactic antibiotics. In New Jersey, people were told to go to their primary care doctors. Why the difference in approach? Which one was better suited to the situation?
Wiersma: I think in deciding how to best give antibiotics out and do the nasal swabs in Florida, I was very much motivated by the experience I'd had in dealing with a large meningitis outbreak in Florida. And the need to just take that on as a public health responsibility and not to delegate it to the private sector. We were seeing already some pressure on pharmacies to get the antibiotics needed to treat anthrax. And really, public health, I think, should be there to assure that everyone who is exposed is really going to get what they need. Without that, there can be a lot of concern and even panic, I think.
We've got some experience in delivering services like this on a mass basis. It's never easy. But I think the lessons we have learned are very useful for each situation.
I think we definitely made some mistakes in the Palm Beach situation. We picked the wrong type of facility -- a facility with too many walls and doors. You need an open facility. There are definitely techniques that work and techniques that don't work.
Knox: What was the problem with the facility?
Wiersma: Again, the meningitis outbreak I had been involved in - we processed 13,500 people between two major holidays, and we did that in three days. It went very smoothly because we picked an open facility where we could design the space to move those people through and respond to surges in demand. For example, when we first put out the information that we were providing a meningitis vaccine to persons in this central Florida community called Palatka, there was a huge outpouring. And we needed to be able to handle that. Then later on it backed off a little bit and we were able to somewhat redesign. But we were able to use an open floor space to, you know, create different lines for people to be able to go in, to create counseling sessions in mass, provide some people on the floor to answer questions, and then add and subtract different processing points or vaccination points as we needed to.
We didn't really have that flexibility in Palm Beach, as you remember. I think you were out there. There were a lot of people standing out in the hot sun and the pouring rain at times. And we couldn't add surge capability and take it away because of simple things like building design we chose.
Knox: So you're figuring that into your planning process right now?
Wiersma: Very much. We finally decided to publish our experience from Palatka meningitis and that's coming out later this year in the Emerging Infectious Diseases journal. And we hope we will offer a good guide for other people trying to do this kind of thing.
Knox: So, in some cases, hospitals and doctors offices are not the best place for handling this kind of thing?
Wiersma: I would say they're probably the worst place. Some things can be delegated to the private sector, some things can't. And when you're talking about mass provision of a service, whether that be an antibiotic or a vaccine or doing swabs, there's definitely some benefit in having a workforce that knows the procedure, can do it over and over the same way each time, can ensure that adequate supplies and antibiotics are there. The real tragedy would be if someone showed up at their doctor's office, didn't have what they needed, and they got sent away. And that person didn't bother to try again. And I think when you're doing that in a mass setting you can avoid some of those pitfalls.
Other things we did wrong -- Well, most of them were related to just processing people. You don't ever keep people outside in the elements. And you always provide a service to them at each step of the process. Even when they're waiting in line you're educating them, answering questions, having them fill out forms. I don't think we used people's time the best possible way.
Knox: There have been several -- at least three times -- in which there have been some smallpox false alarms in the past year. Could you talk about those?
Wiersma: We've responded to several smallpox suspicious cases. One of them was before anthrax. And really it was quite frightening. Because, as you may have heard in people discussing smallpox, it looks quite different from chickenpox usually. And this case looked very much like the real thing.
We had to have a full response. And we realized that some of the capability we needed to have to respond was missing. We did respond. We invited federal colleagues to come join us, to assist us. It turned out this person worked in a pox laboratory so immediately we didn't have a high degree of suspicion for bioterrorism. But this person had inherited a large collection of viruses recently and was doing work on them and we were quite concerned that smallpox might be involved there. It turned out to be a case of disseminated cowpox, which is basically the virus used in smallpox vaccine. And something that we have to get used to dealing with itself. But it definitely tested us.
Knox: So she was exposed as a researcher?
Wiersma: She was exposed to vaccinia and developed disseminated vaccinia infection. Current guidelines would have recommended that she be vaccinated (as a researcher working in that environment), but she wasn't…. There was a failure there.
Knox: What did you discover that you needed in your "response kit" that weren't there?
Wiersma: Real basic things. One of the first things we do in epidemiology is confirm the diagnosis. And we had no real ability to test these specimens. Because the protocols that existed at that time for gathering specimens were very detailed and involved things like having electron micrograph grids and having someone go in there and open the blisters and putting these grids in there to collect material and collecting actually parts of the blisters or the pox vesicles themselves. And having equipment to properly package those up so that no one else could be hurt. We didn't have a lot of those things. And we realized that we couldn't rely on CDC in Atlanta because they were too far away. Their response time was quite lengthy. In fact, in the second case they were fogged in and their response time was very much delayed.
Knox: What about the second case?
Wiersma: The second case was interesting too because it occurred very closely after the first anthrax cases and it was in a person described to us as being a commercial mail carrier. And that of course, you know, got our suspicions up.
Knox: What did you think you were up against?
Wiersma: We didn't know. We thought maybe it was the second attack of a different agent, potentially. In fact, the person handled mail, although this wasn't a U.S. Postal Service employee.
Knox: So here we go again?
Wiersma: So here we go again, exactly. That was our initial thought. Now they're going to try a different agent on us, and this time it's smallpox.
Fortunately we were able to walk them through what was becoming to be an algorithm to guide clinical decisions and is now an algorithm. I think it was more of a concept. And talk to the physicians about the clinical features of the patient and quickly realized this didn't sound very much like smallpox.
But because the index of suspicion was there, and that person was on the scene and we were on the other end of a telephone, we couldn't override the decision. We had to go with it. Which meant sending a team down to collect specimens. Dealing with the patient and protecting other patients that may have been exposed, too. It was a very difficult process.
Knox: You say you couldn't override a decision, what decision are you referring to?
Wiersma: Well, when I talk to a physician on the phone, for example, and they tell me the lesions started on the chest and trunk -- I can tell them there are a lot of possibilities but it sounds like it's not very consistent with smallpox. Maybe even more consistent with chickenpox. If it was smallpox, you'd expect them to be on the extremities first. And we talk about the stage of development of the vesicles. In chickenpox they're all maturing at different rates and some may be encrusted and some are just filling with fluid. In smallpox, they tend to mature in synchronization.
Some of those features -- and there are many other features you can use to compare different diseases -- but some of those features were very much lacking in this case. And the more inconsistent the clinical picture was with smallpox, the more comfortable I felt telling this clinician I don't think you have a smallpox case.
However, in medicine we don't like to overrule the person who's seeing the patient. I'm on other end of a telephone hundreds of miles away. And there are variations of any disease. So I don't think I or anyone in my situation would have felt completely comfortable telling him it absolutely isn't smallpox. I could just suggest that. And again, we needed to do some other things, like gather specimens to show that it was something else -- in this case, chickenpox -- before we could really stand down.
Knox: In determining whether it's chickenpox or not, what procedures were set in motion?
Wiersma: A number of things got set in motion when this and other cases pop up. One is collecting specimens, one is trying to rule in other diagnoses. Another important adjunct we realized is collecting digital photographs. Since I am on the other side of a telephone line, if someone can provide me with a digital photo, and I and other people who are used to looking at different presentations of these diseases could look at them, we might be more comfortable saying yes, this definitely isn't smallpox. Let's stand down. And you can save a lot of money and a lot of concern, at that point. That kind of technology is very much available to us -- and we had digital cameras in our inventory -- but we realized that getting an image on a camera and getting it off the camera to people who need to look at it are two different things. So we need to work on procedures for having our investigators get out there, take a couple of pictures, upload them, put them in an email or whatever and get them to the right people. So that was another thing we learned.
Knox: So people on the scene didn't have that basic training to upload the digital photos?
Wiersma: In this case, nobody even brought a camera to the scene.
The third case we dealt with was very similar to this one, in South Florida. Someone did think to bring a digital camera to the scene, but then we did have those issues of getting it to the right people so it could be useful. I got it several weeks later, but that wasn't exactly useful in making decisions.
Knox: What was the glitch there?
Wiersma: That was the issue of getting it off the camera, just procedural issues and technical issues.
The third case was sometime this year, I would say a couple of months ago. Broward County. A patient who had a very terrible looking rash, bloody lesions all over the body. And the suspicion by the person who saw the patient was that it might be smallpox. Again, that raised an alarm and we tried to go through the algorithm, which by this time is actually on a hard copy and is something we're trying to disseminate to all people that see patients with rash illnesses throughout the state of Florida. We still have a long way to go with that.
So we had some investigators carry over the algorithm and walk clinicians through that. And it very much tries to divide patients into low, moderate or high risk for smallpox. Having done that, I think the clinicians were more and more comfortable that this was probably an unusual presentation of a common disease. Which tends to be more commonly seen than common presentations of unusual diseases, if you can follow that.
But then again, we had the issue of the digital photograph and collecting specimens. Chickenpox is becoming a rare disease in adults because of vaccine. But getting a test to show this was chickenpox wasn't that easy. We didn't know where those lab capacities existed and we realized we also had to map those lab capacities out -- find out which labs can do rapid tests for chickenpox and which ones can't. That way we can help facilitate getting specimens to the right lab.
Knox: And this third case turned out to an unusual chickenpox presentation in an adult?
Wiersma: Yes.
Knox: But I suppose it's a good thing that clinicians are telling you right away when they suspect smallpox?
Wiersma: It is. We hope that clinicians are telling us when they see any unusual disease or a cluster. That's what this enhanced preparedness is all about -- having better connection between private practitioners and other health care professionals and public health so we can respond quickly. There are a lot of systems under development to try to get an earlier jump on detecting bioterrorism. But, you know, basically it all boils down to our ability to take that signal, whether it comes from a system or a phone call and be able to respond to it quickly.
Knox: What's the Merlin system?
Wiersma: The Merlin system is a Web-based disease reporting system that connects 67 county health departments with the state Department of Health It has been an amazing way of modernizing a system that was based on paper and pencil. It has cut many, many days off the lag of reporting disease. But it only operates between counties and the state right now. It has the potential to do even more in its next phase, which is to reach out to physicians and the laboratories. Those are the ultimate sources of case reports. If we can get them reporting on the Web, then we can even further cut down on that time delay.
Knox: What do you need to close that loop?
Wiersma: There are a lot of security issues we have to deal with. Patient confidentiality has always been a very, very high concern. As we move into these digital communication systems we want to make sure we're still ensuring the highest quality and protection of personal information on cases.
Knox: At a very basic level, how would it work?
Wiersma: It would allow the doctor to log into a Web site, or somebody that works in the doctor's office, log onto a Web site and report a disease They're already required to report diseases but usually they do it by phone or by mail. This would allow them to report electronically. And we need to develop incentives for them to do that as well -- let them see information on cases they're reporting. For example, they should be able to get a snapshot of what's going on with meningitis at the same time they're reporting a case of meningitis. I think it will make it more useful and more real to them.
So we're building those systems. Right now it's easy for us to have counties report cases because we're all on a closed intranet that doesn't open up a lot of opportunities for breaches of confidentiality. But as we make this kind of database available to people out in the private sector, we have to look at different ways of securing that information.
Knox: When do you expect to achieve that doctor link?
Wiersma: We're going to pilot a couple this calendar year. So I think we've got momentum on our side now. People realize how powerful this technology is for reporting diseases and communicating about diseases. I think that was the major issue to be dealt with. Now I think things will move quite rapidly.
Knox: Are other states doing this?
Wiersma: Yes. We were not the first. We were one of four or five early adopters. Now the federal government has an initiative to make -- to facilitate, not to make anyone do anything -- but to facilitate all states getting on board. Unfortunately, I think they've taken a little bit more elaborate time-consuming approach than we took in Florida. There have been a number of delays in rolling that out. But it is coming for all states.
Knox: I can see its utility for streamlining the reporting of everyday, non-terroristic diseases, but what's its utility in the context of bioterrorism?
Wiersma: I think you're right, its utility for the bioterrorism context is somewhat limited. And we're looking at other aides to detecting a bioterrorism attack that don't necessarily include Merlin. Although one thing I think we will use Merlin for that will help us very much in our bioterrorism response -- in addition to having all these diseases be reportable in the state of Florida and have them go into this Merlin system, we've always told physicians if they don't even have a name associated with it, if you're a doctor in the community and you see a cluster of patients, that is a reportable event.
We didn't really have a place to capture that information, and Project Merlin will allow those kind of clusters of non-named diseases. For example, I've seen several children in my practice today with a different-looking rash and high fevers. Once that information is reported, it can be linked to information on similar reports from other parts of the state and possibly be that first tip-off.
Don't forget that when Dr. Larry Bush (the JFK Medical Center doctor who saw the first anthrax patient, Bob Stevens) called the county, and then when I talked to him about the unusual case he was seeing, he was not calling about a case of anthrax.
He was calling about an unusual presentation of a disease and an unusual laboratory finding, that being the gram stain of the CS fluid on that first patient. And we had a dialogue. We were able to facilitate additional testing at our Florida state laboratory. It's all part of a process, and I think anything we can do to streamline the process and make it easier to exchange information will help us in detecting a bioterrorism attack.
Knox: Why are some skeptical about syndromic surveillance?
Wiersma: Syndromic surveillance may be good. I think it really should be viewed as a research project at this time. I think there are a lot of competing priorities right now for public health to look at, and how to best get prepared for detecting an attack. And I think to put too much emphasis on large computer systems that all have their own potential lag times associated with them is a potential pitfall that we all need to take seriously.
I know, for example, that when Dr. Larry Bush picks up the phone and calls Dr. Jean Malecki, who then calls me, I have a system that works. What's in that black box and whether it will be able to really detect an event is a question.
And those are all those things we're calling syndromic surveillance right now -- different ways we can look at syndromes before they become named diseases. But the jury is still out on whether those are effective and whether they will work. What is not in question is the system we have now. So I think in the meantime, while we develop these systems and do research on them and explore them, we need to make sure the systems we have today that will work aren't underutilized. That every physicians who's supposed to be reporting knows the phone number they're supposed to pick up and call.
I know that a large number of physicians in Florida don't know who to call if they see something strange. And we need to make sure some of this older technology of telephones and person-to-person communication continues to work, because it has proven to be a way we can detect and respond to events.
Knox: It strikes me that many of the things you're talking about in public health are very basic, concrete, commonsense approaches. It can be complicated, but it's not necessarily high-tech.
Wiersma: That's right. Public health has benefited a lot from new developments in technology. And I think it will continue to develop. And I have high hopes for systems that collect all the electronic data that's already being collected, mainly for the purpose of paying bills between different parties. If that can be used in any way -- or other systems can be used -- to detect a bioterrorism event in a rapid amount of time, I think that would be a tremendous breakthrough.
But at the same time, a lot of what we do, and the reason a lot of our work gets called shoe-leather epidemiology, is because it takes a lot of getting out there and interacting with people and talking to people. And we don't want to neglect the obvious in search of some new panacea. If we can pursue both goals, that's great, but I think we definitely need to maintain the traditional forms of disease surveillance that we do, which is based upon people interacting with each other.
Knox: Do you worry that there's almost too much to do at once in order to get us where we need to be on bioterrorism preparedness? Do you worry about sacrificing other day-to-day problems?
Wiersma: I do. There are a lot of competing priorities in public health right now. Fortunately, a lot of guidelines we've gotten from the federal government on how to prepare for bioterrorism are not set to develop a standard approach that's only good for bioterrorism. And I think that's a very wise approach -- to say, everything we do should be geared toward the overall benefit of a robust public health system that can deal with bioterrorism as well as other threats. As long as we keep that perspective, I think we will have a good balance in our time and where we make our investments.
Knox: If you were to put Florida on a scale of where the state is in terms of preparedness versus where it needs to be, where would it fall?
Wiersma: I have a very hard time answering the question. I'm afraid I might be just a little too frank with my response, because I know a lot. And I have very high expectations of our public health system. I can't answer that.
Knox: That doesn't sound like a very high score.
Wiersma: I don't really have a score to assign. I know we're improving. That's the most important thing. In epidemiology, trends are the most important thing, and the trend line is very positive. But we clearly have a long way to go.
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